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Messrs.  Macmillan  &  Co. 
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BRAIN: 


A   JOURNAL    OF    NEUROLOGY. 


EDITED  BY 


■\ 


J.  C.  BUCKNILL,  M.D.,  F.R.S., 

J.  CRICHTON-BROWNE,  M.D.,  LL.D., 

D.  FERRIER,  M.D.,  F.R.S.,  and 

J.  HUGHLINGS-JACKSON,  M.D.,  F.R.S. 


ft 

VOL.  III. 

April  1880  to  January  1881. 


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MAC  MILL  AN     AND     CO. 
1881. 


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LONDON: 
PRINTED  BY  WILLIAM  CLOWES  AND  SONS,  LOOTS* 

8TAMFOKD   STliEKT   AND  <  IIAIUNU    C'UOSS. 


CONTENTS. 


ORIGINAL  ARTICLES  :— 

A  Plea  for  the  Neurotic  Theory  of  Gout.    By  Dyce  Duckworth,  M.D. 

(Edin.)         .         .         .    '     .         .         .         .         .         .         .         1 

The  Conditions  of  the  Unipolar  Stimulation  in  Physiology  and  Thera- 
peutics.    By  A.  de  Watteville,  M.A.,  B.Sc.         .         .         .  .23 

The   Anatomy  and  Physiology  of  the  Chorda  Tympani  Nerve.     By 

Horatio  R.  Bigelow,  M.D 43 

On  the  Paralysis  which  Results  from  Angular  Curvature  of  the  Spine. 

By  John  Duncan,  M.D.  ........       48 

On  Some  Varieties  of  Cervical  Paraplegia.  By  Thomas  Buzzard,  M.D.  57 
Distribution  of  the  Arteries  of  the  Spinal  Cord.  By  James  Ross,  M.D.  80 
On  the  Form  and  Topographical  Relations  of  the  Corpus  Striatum.    By 

Professor  J.  C.  Dalton  (New  York)  .         .         .         .         .         .145 

Nystagmus.    By  R.  P.  Oglesby 160 

On  Muscular  Spasms  known  as  "  Tendon-Reflex."  By  A.  Waller,  M.D.  179 
On  Right  or  Left- sided  Spasm  at  the  Onset  of  Epileptic  Paroxysms,  &c. 

By  J.  Hughlings- Jackson,  M.D.,  F.R.S 192 

Notes  on  Left-handed  ness.     By  William  W.  Ireland,  M.D.  .         .207 

Optical  Illusions  of  Motion.     By  Professor  Silvanus  P.  Thompson,  B.A., 

D.Sc 289 

On  some  Points  in  the  Diagnosis  and  Treatment  of  Brain  Disease.     By 

Julius  Althaus,  M.D 299 

Recurrent  Headaches  in  Children.  By  Francis  Warner,  M.D.  .  .  309 
On  the  Methods  of  Preparing,  Demonstrating,  and  Examining  Cerebral 

Structure  in  Health  and  Disease.     By  Bevan  Lewis,  L.R.C.P.      314,  502 
Nervous  Diseases  in  Victoria.     By  James  Jamieson,  M.D.  .  .     337 

A  Plea  for  the  Minute  Study  of  Mania.  By  J.  Crichton-Browne,  M.D.  347 
On  Temporary  Paralysis  after  Epileptiform  and  Epileptic  Seizures.     By 

J.  Hughlings-Jackson,  M.D. 433 

Piscidia  Erythrina.     By  Isaac  Ott,  M.D. 452 

Cerebral  Amblyopia  and  Hemiopia.  By  David  Ferrier,  M.D.  .  .  456 
Visible  Muscular  Conditions  as  Expressive  of  States  of  the  Brain  and 

Nerve-Centres.     By  Francis  Warner,  M.D.         ....     478 

Tetanus.    By  Surgeon-Major  Ratton,  M.D 496 

On  the  Methods  of  Preparing,  Demonstrating,  and  Examining  Cerebral 
_     Structure  in  Health  and  Disease.     By  Bevan  Lewis,  L.R.C.P.       .     502 

a  3 


VI  CONTENTS. 

CRITICAL  DIGESTS  AND  NOTICES  OF  BOOKS:— 

PAGE 

Nothnagel  on  the  Regional  Diagnosis  of  Diseases  of  the  Brain.    By  D. 

Ferrier,  M.D 85 

Huxley  on  the  Crayfish.    An  Introduction  to  the  Study  of  Zoology. 

By  F.  Jeffrey  Bell,  M.A 99 

Gowers    on  Pseudo-hypertrophic    Muscular    Paralysis.      By    Robert 

Saundby,  M.D 109 

The  Index  Medicus.    By  J.  Crichton-Browne,  M.D Ill 

Morris  on  Skin  Diseases.  By  J.  Crichton-Browne,  M.D.  .  .  .  112 
Bastian  on  the  Brain  as  an  Organ  of  Mind.    By  John  Charles  Bucknill, 

M.D.,  F.R.S.         .         .         .         .         .         m  ■       .         .         .215 

Lindsay  on  Mind  in  the  Lower  Animals,  in  Health  and  Disease.    By 

F.  L.  Benham,  M.B 225 

Landouzy  on  Paralysis  in  Acute  Disease.    By  A.  de  Watteville,  M.A., 

B.Sc. 233 

Mickle  on  General  Paralysis  of  the  Insane.  By  J.  C.  Bucknill  .  .  239 
Erlenmeyer  on  the  Physiology  and  Pathology  of  Writing.    By  H.  de 

Watteville,  M.D .         r         .         .363 

Brissaud  on  Hemiplegic  Contracture.  By  David  Ferrier,  M.D.  .  .  365 
Scientific  Transcendentalism.  By  F.  L.  Benham,  M.B.  .  .  .374 
Heidenhain  on  Animal  Magnetism.  By  David  Ferrier,  M.D.  .  .  383 
Vulpian's  Maladies  de  la  Moelle.  By  A.  de  Watteville,  M.D.  .  .516 
Aitken  on  the  Science  and  Practice  of  Medicine.  By  J.  Crichton- 
Browne,  M.D 528 


CLINICAL  CASES:— 

Arrest  of  Development  in  the  Left  Upper  Limb,  in  Association  with  an 

Extremely  Small  Right  Ascending  Parietal  Convolution.     By  H. 

Charlton  Bastian,  M.D.,  F.R.S.,  and  V.  Horsley  .  .  .  .113 
Case  of  Nerve-Splitting.  By  Surgeon-Major  K.  M'Leod,  A.M.,  M.D.  .  117 
Cases  of  Intra-Cranial  Tumour.  By  James  Ross,  M.D.  .  .  .  121 
Case  of  Alternate  Hemiplegia,  with  Conjugate  Deviation  of  the  Eyes. 

By  Alexander  M.  McAldowie,  M.D.  .         .         .         .         .125 

Crural  Monoplegia — Limited  Cortical  Lesion  of  Opposite  Hemisphere. 

By  David  Ferrier,  M.D.,  F.R.S 128 

Case  of  Microcephalic  Idiocy.  By  A.  R.  Urquhart,  M.D.  .  .  .  246 
Case  of  Cerebral  Tumour.     By  Arthur  W.  Fox,  M.B.,  and  Ernest  Field, 

M.B 252 

Case  of  Progressive  Muscular  Atrophy.  By  Byrom  Bramwell,  M.D.  .  396 
Case  of  Compound  Fracture  of  the  Skull.    By  T.  Pridgin  Teale,  MA. 

Oxon 400 

Case  of  Athetosis.    By  Lewis  Shapter,  M.D.    .  .402 


CONTENTS.  Vll 

PAGE 

Case  of  Congenital  Absence  of  the  Corpus  Callosum.     By  A.  E.  Urqu- 

hart,  M.D 408 

A  Case  of  Epilepsy.     By  Charles  Mercier,  M.B 532 

Case  of  Hemiplegia  and  Hemianesthesia  in  au  Idiot,  as  the  Result  of 

Paralysis  of  the  Left  Cerebral  Hemisphere.  By  Donald  Fraser,  M.D.  536 

An  Obscure  Case  of  Brain  Disease.     By  M.  Handheld  Jones,  L.R.C.P.  542 


ABSTRACTS  OF  BRITISH  AND  FOREIGN  JOURNALS  :— 

Innervation  des  Vaisseaux  Cutanes  (Dastre  et  Morat).     Etude  sur  la 

Physiologic   des  Nerfs   des  Muscles  Stries  (Tschiriew).      By  A. 

Waller,  M.D .  .  .132 

Primary  Athetosis  (Gnauck).  By  W.  J.  Dodds,  M.D.,  D.Sc.  .  .  136 
A  Case  confirming  Cerebral  Localisation  (Tamburini).    Caizergue's  Case 

of  Cerebral  Localisation.     Lactic  Acid  as  a  Hypnotic.     By  W.  W. 

Ireland,  M.D 137 

Relations  of  Brain,  Mind,  and  Higher  Nerve  Function.     By  W.  G. 

Thompson,  M.D 141 

Traumatic  Insanity.     Bullet  Wound  of  the  Brain.     By  Robert  Lawson, 

M.B 143 

Method  of  Preserving  the  Brain  (Giacomini).      By  Allen  Thomson, 

F.R.S 257 

Krueg  on  the    Sulci    of  the  Zonoplacental   Mammalian   Brain.     By 

H.  Obersteiner 259 

Fere  sur  le  DeVeloppement  du  Cerveau,  &c.     Amidon  on  a  New  Study 

of  Cerebral  Localisation.     By  A.  Waller,  M.B 260 

Visceral  Neurology.     By  J.  Mitchell  Bruce,  M.D 263 

Buzzard  on  certain  Points  in  Tabes  Dorsalis.  By  J.  Hughlings-Jackson  266 
Abstracts  of  the  Gulstonian  Lectures  on  Epilepsy.     By  W.  R.  Gowers, 

M.D 268 

On  the  Disease  called  Sturdy  in  Sheep,  in  its  relation  to  Cerebral 

Localisation.  By  George  T.  Beatson,  B.A.,  M.D.  .  .  .282 
Tripier  on  Anesthesia  from  Cortical  Lesions.     Sommer  on  Diseases  of 

the  Cornu  Ammonis.  By  D.  Ferrier  .....  286 
The  Central  Sulci  in  the  Carnivora  -The  Brain  of  the  Hippopotamus 

—The  Brain  of  the  Bush  Dog.  By  J.  C.  Galton,  M.A.  .  .  413 
Exner  on  Cerebral  Localisation.  By  H.  Obersteiner  .  .  .  .  416 
Brachial  Monoplegia — Pitres  on  Cerebral  Localisation — Kronecker  and 

Nicolaides  on  Irritation  of  the  Vaso-Motor  Centres  by  Summation 

of  Electrical  Stimuli — Marckwald  and  Kronecker  on  the  Respiratory 

Centres — Ferrier  and  Yeo  on  the  Cerebral  Visual  Centres — Debove 

and  Gombault  on  the  Decussation  of  the  Sensory  Tracts  in  the 

Medulla  Oblongata — Debove  and  Boudet  on  Ataxic  Incoordination 

— Gaskell  on  the  Tonicity  of  the  Heart  and  Blood-vessels — Gombault 


Vlll  CONTENTS. 

PAGE 

on  Segmentary  Peri-axillary  Neuritis — Grasset  on  Locomotor  Ataxy 
and  Heart  Disease — Tschiriew  on  Lesions  of  the  Spinal  Cord  and 
Skin  in  a  Case  of  Anesthetic  Leprosy — Pott's  Disease  and  Progres- 
sive Muscular  Atrophy.     By  David  Ferrier,  M.D.        .         .         .     417 

Kahler  and  Pick  on  the  Pathology  and  Pathological  Anatomy  of  the 

Central  Nervous  System.     By  W.  J.  Dodd,  D.Sc.        .         .         .427 

Boyer  and  Decaisne  on  Cortical  Lesions.     By  A.  R.  Urquhart,  M.D.     .     430 

Magnan    on   Word    Blindness — Delaunay  on    Memory.      By   A.   R. 

Urquhart,  M.D 552 

Buzzard  on  Transfer-Phenomena  'in  Epilepsy  produced  by  Encircling 

Blisters.    By  J.  Hughlings-Jackson,  M.D.  ....     554 

Luederitz  on  Experiments  on  the  Effect  of  Pressure  on  Motor  and 
Sensory  Nerves,  &c. — Brieger  on  Paralysis  from  Fright.  By  R.  H. 
Pierson,  M.D 555 

Onimus    on    Modifications   in   the    Excitability   of   the  Nerves  and 

Muscles  after  Death.     By  A.  Waller,  M.D 556 

Striiinpell  on  the  Pathology  of  the  Spinal  Cord — Westphal  on  Syphilis 
and  Tabes  Dorsalis — Pick  on  Agenesis  of  the  Spinal  Cord — Moeli 
on  Amyotrophic  Lateral  Sclerosis — Shaw  on  Sub-acute  Myelitis 
of  the  Anterior  Cornua.     By  W.  J.  Dodds,  M.B.,  B.Sc.         .         .     560 

Erlenmeyer  on  Nerve-Stretching  in  Locomotor  Ataxia — Muller  on  the 
Early  Stage  of  Locomotor  Ataxy — Erlenmeyer  on  the  Paradoxical 
Muscular  Contraction — Schulz  on  Injury  of  the  Spinal  Cord — 
Dujardin-Beaumetz  on  iEsthesiogenic  Properties  of  certain  Woods 
applied  to  the  Skin — Berger  on  the  Nosology  of  Tabes  Dorsalis — 
Ballet  on  Facial  Monoplegia.    By  A.  de  Watteville,  M.D.    .         .     569 

Maragliano  on  the  Nitrite  of  Amyl  in  Epilepsy.  By  W.  W.  Ireland,  M.D.     575  * 


(     ix     ) 


LIST  OF  CONTRIBUTORS. 


ALTHAUS,  JULIUS,  M.D. 
BASTIAN,  B.  CHARLTON,  M.D. 
BEATSON,  GEORGE  S.,  M.D., 
BELL,  F.  JEFFREY,  M.A. 
BENHAM,  F.  L.,  M.B. 
BIGELOW,  HORATIO  R.,  M.D. 
BRAMWELL,  BYROM,  M.D. 
BRUCE,  J.  MITCHELL,  M.D. 
BUCKNILL,  J.  C,  M.D. 
BUZZARD,  THOMAS,  M.D. 
CRICHTON-BROWNE,  J.,  M.D. 
DALLEN,  J.  C,  M.D. 
DE  WATTEV1LLE,  A.,  B.Sc. 
DODDS,  W.  J.,  M.D. 
DUCKWORTH,  DYCE,  M.D. 
DUNCAN,  JOHN,  M.D. 
FERRIER,  DAVID,  M.D. 
FIELD,  ERNEST,  M.B. 
FOX,  ARTHUR  W.,  M.D. 
FRASER,  DONALD,  M.D. 
GALTON,  J.  C,  M.D. 
GOWERS,  W.  R.,  M.D. 
HORSLEY,  V. 
HUGHL1NGS-JACKSON,  J.,  M.D. 


IRELAND,  W.  W.,  M.D. 
JAMIESON,  JAMES,  M.D. 
JONES, M.  HANDFIELD,  L.R.C.P. 
LAWSON,  ROBERT,  M.B. 
LEWIS,  BEVAN,  L.R.C.P. 
McALDOWIE,  A.,  M.D. 
McLEOD,  KENNETH,  M.D. 
MERCIER,  CHARLES,  M.B. 
OBERSTEINER,  II.,  M.D. 
OGLESBY,  R.  P. 
OTT,  ISAAC,  M.D. 
PIERSON,  R.  H.,  M.D. 
RATTON,  J.  J.  L.,  M.D. 
ROSS,  JAMES,  M.D. 
SAUNDBY,  ROBERT,  M.D. 
SHAPTER,  LEWIS,  M.D. 
TEALE,  T.  PRIDGIN,  M.A. 
THOMPSON,  ALLEN,  M.D. 
THOMPSON,  SILVANUS  P.,  D.Sc. 
THOMPSON,  W.  G.,  M.D. 
URQUHART,  A.  R.,  M.D. 
WALLER,  A.,  M.D. 
WARNER,  FRANCIS,  M.D. 


(     xi      ) 


LIST  OF  ILLUSTKATIONS. 


Distribution  of  the  Arteries  of  the  Spinal  Cord  : —  page 
Fig.  1.  Schematic  Representation  of  the  Distribution  of  the  Blood- 
Vessels  in  the  Cord  ( Woodcut)            .          .          .          .          .81 

Arrest  of  Development  in  the  Left  Upper  Limb :  3  Figures  (Plate)      .  113 

Form  and  Topographical  Relation  of  the  Corpus  Striatum  (  Woodcuts)  : — 

Fig.  1.  Brain  in  Transverse  Vertical  Section       ....  147 

Fig.  2.  Brain  of  Fox  (Profile  view)  .         .         .         .         .         .148 

Fig.  3.  Human  Brain  (Profile  view)           .....  149 

Fig.  4.  Human  Brain ;  Median  Surface  of  the  Right  Hemisphere  .  151 
Fig.  5.  Longitudinal  and  Vertical  Section  of  the  Right  Hemisphere, 

showing  Cavity  of  Lateral  Ventricle  (seen  from  the  Inner  Side)  153 
Fig.  6.  Longitudinal  and  Vertical  Section  of  the  Right  Hemisphere, 
through  Corpus  Striatum  and  Surcingle  (seen  from  the  Inner 

Side) 156 

Fig.  7.  Horizontal  Section  of  the  Brain,  through  the  Anterior  Com- 
missure and  Lower  Part  of  the  Cerebral  Ganglia  .         .         .  158 

■  Tendon-ReBex  "  (  Woodcuts)  :— 

Fig.  1.  Nerve  Transmission  Rapidity         .....  186 

Fig.  2.  Knee-Clonus 187 

Fig.  3.  Ankle-Clonus 187 

Fig.  4.  Tendon-percussion  Latency  of  Rectus      ....  188 

Fig.  5.  Tendon-percussion  Latency  of  Gastrocnemius  .         .         .  188 

Fig.  6.  Electric  Latency  of  Rectus 189 

Microcephalic  Idiocy : — 

Head-measurements  (half  Life-size)  of  E.  F.        .         .         .         .  250 

Optical  Illusions  of  Motion  (Four  Woodcuts)     ....       292-295 

Functional  Athetosis 402 


XI I  LIST  OF   ILLUSTRATIONS. 

Cerebral  Amblyopia  and  Heminpia  (Plates)  : —  page 

Plate  1.  Field  of  Vision,  R.  and  L.,  of  Thomas  H.  .         .     460 

Plate  2.  Field  of  Vision,  R.  and  L.,  of  Hannah  0.      .         .         .     462 
Plato  3.  Field  of  Vision,  R.  and  L.,  of  James  S.  475 

Charcot's  Scheme  of  Optic  Tracts  (  Woodcut)     .....     464 

Visible  Muscular  Conditions  as  Expressive  of  Slates  of  the  Brain  and 
Nerve  Centres  (  Woodcuts) : — 

The  Nervous  Hand ;  the  Energetic  Hand ;   the  Hand  at  Rest ; 
the  Straight  Hand 494 

Cerebral  Structure  in  Health  and  Disease;   Diagram  Illustrative  of  the 

Effects  of  Embolic  Plugging:  after  Kindfleisch  (Woodcut)    .  .     511 

Hemiplegia  and  Hemianesthesia  in  an  Idiot  Boy  (  Woodcuts)  : — 

Cells  of  the  Brain .         .         .540 

Obscure  Case  of  Brain  Disease  (Woodcut)  .....     547 


BBAIN. 

APRIL,  1880. 

Original  fortifies. 
A  PLEA  FOE  THE  NEUROTIC  THEORY  OF  GOUT. 

BY  DTCE   DUCKWOKTH,   M.D.   EDIN., 

Fellow  of  the  Royal  College  of  Physicians,  Assistant-Physician  to 
St.  Bartholomeio's  Hospital. 

"  The  difficulties  and  refinements  relating  to  the  disease  itself  ....  I  will 
leave  for  Time,  the  guide  to  truth,  to  clear  up  and  explain." 

A  Treatise  on  Gout  and  Dropsy,  Sydenham,  1683. 

I  venture  in  the  present  essay  to  put  forward  some  argu- 
ments which  tend,  in  my  opinion,  to  sustain  the  thesis,  that 
gout  is  a  malady  of  neurotic  origin. 

In  the  first  place,  I  wish  to  clear  myself  from  a  charge  that 
may  be  brought  against  any  one  who  seeks  to  promulgate  such 
a  view.  I  must  confess  that  I  am  not  bound  to  any  one-sided 
theory  of  disease,  in  general ;  that  I  am  not  a  rampant  neuro- 
pathologist ;  and  that  I  am  constantly  endeavouring  to  seek 
exactness  and  truth  in  medicine.  And,  having  said  this 
nuch,  I  may  pass  on  to  state  that,  having  been  a  pupil  and 
intimate  friend,  for  many  years,  of  the  late  Professor  Laycock, 
I  have  not  failed  to  imbibe,  and  to  weigh  very  carefully,  the 
doctrines  laid  down  by  him  on  many  matters  of  profound 
interest  in  practical  medicine  and  pathology.  I  have  carried 
these  views  along  with  me,  and  have  applied  them,  day  by 
day,  to  the  facts  which  have  come  before  me  in  the  course 
of  hospital  experience.  At  my  hands,  therefore,  these  views 
have  received  the  roughest  and  most  work-a-day  application. 

VOL.   III.  b 


2     A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT. 

*  Grout  is  primarily  and  pre-eminently  a  neurosis."  So  wrote 
Laycock  to  me  a  year  before  his  death.  His  great  predecessor 
in  the  Edinburgh  Chair  of  Practice  of  Physic,  Cullen,  taught 
the  same  doctrine. 

"  Gout  is  manifestly  an  affection  of  the  nervous  system,  in 
which  the  primary  moving  powers  of  the  whole  system  are 
lodged.  The  occasional  or  existing  causes  are  almost  all  such 
as  act  directly  upon  the  nerves  or  nervous  system,  and  the 
greater  part  of  the  symptoms  of  the  atonic  or  retrocedent  gout 
are  manifestly  affections  of  the  same  system.  This  leads  us  to 
seek  for  an  explanation  of  the  whole  of  the  disease  in  the  laws 
of  the  nervous  system,  and  particularly  in  the  changes  which 
may  happen  in  the  balance  of  its  several  parts.  Of  the 
several  pyrexiae  which  are  diseases  of  the  sanguiferous  system, 
some  are  with,  and  others  without  a  considerable  affection  of 
the  nervous  system :  pyrexia  and  neuroses,  therefore,  are 
necessarily  and  unavoidably  mixed  more  or  less  with  one 
another.  Of  those  which  are  mixed,  gout  is  a  principal 
instance,  in  so  far  as  it  is  an  inflammatory  disease ;  like 
rheumatism,  it  is  placed  among  the  pyrexiae,  but  it  is  among 
the  limits  between  pyrexia  and  neuroses,  and  shows  more  than 
any  other  pyrexia  does  of  an  affection  of  the  nervous  system." * 

Cullen  states  that  he  adopted  his  views  as  to  the  nervous 
causes  of  gout  from  Stahl.2 

Within  the  last  few  years,  large  progress  has  been  made  in 
the  study  of  nervous  disease,  and  quite  recently,  in  particular, 
has  light  been  shed  upon  various  affections  of  the  joints,  which 
can  now  with  certainty  be  relegated  to  disorders  of  the  central 
nervous  system. 

Few  writers  have  approached  this  subject  since  Professor 
Laycock  put  forward  his  views,  and  these,  indeed,  were  never 
fully  developed  by  him. 

His  most  minute  description  is  given  as  follows :  "  Ex- 
cessive activity  of  the  nervous  system,  or  of  portions  of  it, 
becomes  a  highly  predisposing  cause  of  the  neuroses,  as  of 

1  '  First  Lines  of  the  Practice  of  Physic,'  vol.  ii.  part  i.  chap.  xiv.  Edited  by 
John  Thomson,  M.D.  Edin.,  1827. 

2  <  Theoria  Medica  Vera,'  &c.  G.  E.  Stahl.  (Halle,  1737.)  "  De  Doloribus 
Spasticis  Arthritico-Podagricis,"  §  xxxviii.  p.  1040. 


A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT.     3 

other  general  diseases.  .  .  .  These  excesses,  when  habitual  or 
long  continued,  are  apt  to  develop  hereditary  tendencies. 
Thus,  great  mental  labour,  drunkenness,  strain  on  special 
nerves,  and  the  like,  of  parents,  are  often  manifested  in 
children  as  neuroses.  Here  the  influence  of  the  nerve-centres 
on  the  nutrient  forces  of  tissue  is  shewn,  as  in  hereditary 
insanity,  epilepsy,  hysteria,  angina  pectoris,  and  even,  gouty 
diseases  in  general,  which,  primarily,  are  neurose  degenerations 
in  the  nutrition  and  transformation  of  certain  tissues." l 

The  exceptions  I  have  alluded  to,  I  must  pause  to  refer  to 
briefly.  The  first  consists  in  a  paper  which  was  written  by 
Dr.  Austin  Meldon  of  Dublin,2  in  which  he  makes  objection  to 
the  uric  acid  theory  as  explaining  fully  the  cause  of  gout.  He 
quotes  cases  to  show,  as  is  well-known  and  recognised,  that  uric 
acid  and  urates  may  exist  in  the  blood  to  large  extent  without 
giving  rise  to  gout,  or  being  the  result  of  gouty  taint  or 
inheritance,  and  he  invokes  the  nervous  portion  of  Cullen's 
theory  to  "complete  the  chain.'.'  His  theory  is  as  follows. 
He  believes  that  the  presence  in  the  blood  of  uric  acid  and  of 
soda,  in  some  form,  constitutes  the  predisposing  cause  of  gout. 
"  Nerve-force,  when  in  a  healthy  condition,  preserves  these  two 
in  a  fluid  state,  separately,  in  a  condition  in  which  they  may 
be  eliminated  by  the  skin,  kidneys,  or  bowels.  As  soon,  how- 
ever, as  this  nerve-influence  is  lessened,  these  two  substances 
unite  in  the  tissues  most  removed  from  the  brain  and  centre  of 
circulation.  Irritation  and  inflammation  excite  the  nervous 
system  to  increased  energy,  and  the  disease,  for  the  time,  is 
arrested."  Dr.  Meldon  lays  stress  upon  the  fact  of  the  attacks 
occurring  mostly  at  night,  when  the  nerve-force  and  circulation 
are  feeblest,  upon  the  common  implication  of  the  big  toe,  and 
notes  the  marked  effect  of  depression  of  the  nervous  power  as 
an  important  factor  in  their  production.  This  theory,  then,  is 
a  compound  or  humoro-neurotic  one. 

The  second  exception  I  have  referred  to  above  is  a  very 
notable  one.  I  allude  to  the  views  of  Dr.  Edward  Liveing 
which  were  published  in  his  masterly  exposition  of  the  subject 

1  •  The  Principles  and  Methods  of  Medical  Observation  and  Research.'   Edit.  2 
(Edin.  1864),  p.  338. 

2  'Lancet,'  vol.  ii.  (1872), p.  115. 

B    2 


4     A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT. 

of  megrim.  Discussing  the  alliances,  and  the  various  sympto- 
matic forms,  of  megrim,  he  observes  that — "  There  is  much  in 
the  history  of  gout — its  hereditary  character,  limitation  to 
particular  ages  and  sexes,  periodicity,  explosive  character, 
sudden  translations  and  remarkable  metamorphic  relations 
with  nervous  disorders — which  seems  to  stamp  the  malady  as  a 
pure  neurosis;"  and  even  the  fit  itself,  with  its  sudden 
nocturnal  invasion,  the  late  Dr.  Todd  was  accustomed  to 
compare  to  one  of  epilepsy  or  of  asthma.  Moreover,  although 
the  presence  of  uric  acid  in  the  blood  of  gouty  subjects  is  no 
longer  inferential  and  admits  of  ready  demonstration,  the 
dependence  of  the  remaining  phenomena  of  gout  upon  this 
associated  condition,  is,  to  say  the  least,  far  from  proved ;  and 
it  is  further  certain  that  uric  acid  is  also  present  in  excess 
under  other  pathological  conditions  which  have  no  connection 
whatever  with  gout.  On  the  whole,  there  is  much  to  be  said 
in  support  of  the  view  that  gout  in  its  various  forms  is  the 
manifestation  of  a  disorder  which  has  its  primary  seat  in  the 
nervous  system  itself;  and  there  is  no  more  difficulty  in  con- 
ceiving that  inflammation  and  pain  may  be  an  effect  of 
deranged  innervation  in  the  case  of  arthritis,  than  in  the 
analogous  case  of  herpes  zoster ;  or  that  an  excess  of  uric  acid 
should  be  generated  or  retained  in  the  system  under  a  similar 
influence,  than  that  sugar  should  in  the  parallel  case  of  the  dia- 
betes which  follows  a  lesion  in  the  floor  of  the  fourth  ventricle." ' 
As  bearing  on  this  subject,  Sir  James  Paget 2  remarks  that 
"disturbance  of  the  nervous  system  in  some  form  and  part 
may  be  regarded  as  a  factor  in  every  case  of  gout.  There  are 
reasons  enough  for  thinking  that  changes  in  the  nervous 
centres  determine  the  locality  of  each  gouty  process,  while 
changes  in  the  relations  of  the  blood  and  tissues  determine  its 
method  and  effects ;  and  that  thus  we  may  explain  the  sym- 
metries of  disease  in  gout,  sometimes  bilateral,  sometimes 
antero-posterior,  and  thus  its  metastases.  But  these  changes 
are  a  part  of  the  pathology  of  gout  which  is  not  yet  clinical."  3 

1  '  On  Megrim,  Sick-Headache,  and  some  Allied  Disorders.'     By  Edward 
Liveing,  M.D.  Cantab.  (Lond.  1873),  p.  404. 

a  « Clinical  Lectures  and  Essays.'    Edit.  2  (1879),  p.  382. 

3  '  Studies  of  Some  Irregular  Manifestations  of  Gout '  (1879),  p.  93. 


A  PLEA  FOE  THE  NEUROTIC  THEORY  OF  GOUT.     5 

In  a  paper  published  last  year  in  the  15th  Volume  of 
St.  Bartholomew's  Hospital  Beports,1  I  alluded  to  these  views 
of  Cullen,  Lay  cock,  and  Liveing,  and  quoted  the  teaching  of 
Lay  cock  on  this  subject,  showing  how  he  regarded  the  per- 
verted chemistry  of  gout  merely  as  an  epiphenomenon  of  a 
more  profound  and  overruling  neurosis ;  and  I  ventured  to 
predict  that  at  no  distant  period  Cullen's  assertions  would  be 
more  completely  verified  and  vindicated.  Cullen's  views  have 
been  vigorously  combated  by  Dr.  Garrod  in  his  classical  work 
on  gout,  but  I  venture  to  think  that  with  additional  evidence 
now  forthcoming,  and  by  the  light  of  other  modern  doctrines 
established  since  Cullen's  day,  the  teaching  of  that  illustrious 
man,  with  certain  modifications,  may  not  unfairly  be  sustained 
at  the  present  time. 

Gout  has  certainly  held  its  place  for  a  long  time  in  humoral 
pathology,  and  although  Cullen's  views  tended  to  overthrow 
the  theory  of  any  special  morbid  state  of  the  fluids,  it  does  not 
appear  that  any  marked  attention  was  paid  to  the  nervous 
part  of  his  aetiology.  More  stress  was  laid  by  his  followers 
upon  that  portion  of  his  theory  which  embraced  the  tone  or 
atony  of  the  system.  Cullen  held  that  loss  of  tone  occurred  in 
the  extremities,  and  that  this  atonic  state  was  communicated 
to  the  whole  system,  but  especially  to  the  stomach.  He 
believed  that  nature  restored  the  lost  tone  by  setting  up  an 
inflammatory  affection  in  the  extremities. 

He  further  developed  from  this  more  fanciful  theories,  to 
explain  different  varieties  of  gout,  such  as  atonic,  misplaced, 
and  retrocedent.  Such  views  as  these  are  hardly  perused  with 
patience  in  these  days,  and  the  promulgator  of  them  is 
naturally  regarded  as  an  effete  authority.2  But  it  is  possible, 
I  believe,  to  rescue  from  oblivion,  and  to  develop  more  fully, 
Cullen's  theory  as  to  gout  being  first,  "a  disease  of  the  whole 
system,  depending  upon  a  certain  general  conformation  and 

1  Mr.  Spencer  Wells  has  called  attention  to  the  highly  developed  nervous 
system  of  the  gouty,  and  to  the  influence  of  irregular  exercise  of  it,  in  inducing 
paroxysms. — 'Practical  Observations  on  Gout,'  etc.  (1854),  p.  21. 

2  "  The  view  of  the  solidists,  represented  by  Cullen,  who  considered  gout  to 
be  an  affection  of  the  nervous  system,  has  never  been  able  to  hold  its  ground 
against  the  various  humoralistie  theories."  Senator,  'Ziemsscn's  Cyclopaedia,' 
Art.  Gout,  p.  101,  Eng.  Translation. 


6     A  PLEA  FOE  THE  NEUROTIC  THEORY  OF  GOUT. 

state  of  body ;" 1  and  secondly,  that  it  "  is  manifestly  an 
affection  of  the  nervous  system." 

The  researches  of  Dr.  Garrod  seemed  to  place  the  modern 
pathology  of  gout  upon  a  fresh  and  secure  humoral  basis.  His 
facts  respecting  the  uric-acid-excreting  function  of  the  kid- 
neys, and  the  relations  between  this  acid  and  the  disease, 
have  not  been  controverted,  and  they  constitute  a  solid 
advance  in  medical  science,  which  must  ever  remain  most 
honourably  associated  with  his  name.  Still,  Garrod,  with  a 
degree  of  caution  becoming  his  scientific  position,  allows  that 
his  views  are  "in  themselves  insufficient  to  explain  all  the 
phenomena  of  gout."  He  has  endeavoured  to  meet  every 
difficulty  which  opposed  itself  to  his  own  theory,  and,  it  must 
be  allowed,  with  great  power  and  ingenuity.  But  he  has  no- 
where availed  himself  of  any  view  which  would  admit  the 
interposition  of  nervous  influence,  and  he  does  not  attempt  to 
combat  Cullen's  particular  theory  of  the  specific  involvement 
of  the  nervous  centres.  Sir  Charles  Scudamore,  who  criticised 
Cullen's  views,  also  took  no  heed  of  the  alleged  implication  of 
the  nervous  system,  and  adopted  a  humoral  theory,  starting 
from  the  stomach.2  In  more  recent  times  too,  the  late  Dr. 
Murchison  gave  in  his  full  adherence  to  a  humoral  theory  of 
gout,  and  expressed  himself  thus :  "  I  hold  that  what  is  called 
a  'gouty  diathesis'  always  indicates,  and  is  the  result  of 
hepatic  derangement,  and  that  many  symptoms  commonly 
referred  to  gout,  would  be  more  correctly  ascribed  to  disorder 
of  the  liver.  .  .  .  Gout  itself  is  merely  one  of  the  results  of 
lithaemia."3  The  idea  that  gout  was  in  any  way  a  mani- 
festation of  disturbed  nervous  relations,  seems  never  to  have 
been  contemplated  by  that  very  thoughtful  and  philosophical 
physician. 

In  a  suggestive  communication  by  Dr.  Ord,4  on  the  relations 
of  uric  acid  to  gout,  he  offers  the  view  that  the  malady  is  a 

1  Op.  cit.,  par.  dxxx. 

2  'A  Treatise  on  the  Nature  and  Cure  of  Gout  and  Gravel,'  edit.  4  (1823), 
pp.  10  and  147.  Cullen's  "  third  observation  "  was,  that  the  stomach  was  the 
internal  part  most  frequently  and  considerably  affected  by  gout,  yet  he  repudiated 
any  humoral  pathology  in  connection  with  it. 

3  '  Lectures  on  Diseases  of  the  Liver.'     Edit.  2  (1877),  p.  568. 

4  'Medical  Times  and  Gazette,'  vol.  i.  (1S74),  p.  233. 


A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT.     7 

special  form  of  degeneration  or  want  of  tissue-organisation  in 
remote,  and  lowly  vascular  parts.  He  believes  that  the  uratic 
deposits  result  from  either  general  or  local  disintegration,  and 
are  not  to  be  regarded  as  significant  of  their  elimination  from 
the  blood  :  further,  that  the  local  processes  are  not  dependent 
on  these  deposits,  and  that  the  latter  are  not  the  result  of  the 
inflammation.  He  takes  cognizance  of  nervous  influence  so 
far  as  to  affirm  that  "  all  authors,  in  one  way  or  another,  admit 
the  direct  influence  of  the  nervous  system  "  (which  statement  I 
can  hardly  agree  with),  and  he  believes  that  local  gouty 
"  degenerations  and  inflammation  tend  to  infect  the  rest  of  the 
system  through  the  blood,  and  to  set  up  similar  actions  elsewhere 
through  reflex  nervous  action." 

Dr.  Ord's  theory  is  therefore  mainly  humoral,  and  he  is 
chiefly  concerned  to  combat  Garrod's  views. 

To  discuss  more  in  detail  the  question  of  the  humoral 
element  in  the  pathology  of  gout,  is  not  within  the  scope  of 
the  present  essay. 

It  is,  without  doubt,  the  case  that,  hitherto,  no  theory  has 
been  set  forth  which  appears  to  embrace  all  the  multiform  phe- 
nomena of  gouty  disease.  The  greatest  advance  of  modern 
research  has  been  to  establish  the  certainty  of  some  special 
relation  to  it,  in  the  greater  number  of  instances,  of  uric  acid, 
and,  so  far,  there  is  clear  warrant  for  retaining  a  measure  of 
humoral  pathology  in  our  conception  of  the  malady.  There  is 
still  much  to  be  done  in  elucidating  the  causes  of  the  renal 
inadequacy  which  must  be  taken  into  the  consideration  of  a 
comprehensive  pathology  of  gout. 

The  best  approach  to  the  line  of  argument  I  purpose  to 
take  up,  will  manifestly  be  to  review  the  special  characters  of 
neuroses  in  general,  and  then  to  examine  coincidently,  how 
far  the  well-ascertained  features  of  gout  conform  to  such 
characters. 

Before  proceeding  to  this  analysis,  I  would  first  assert  that 
gout  is  something  beyond  the  mere  resultant  effects  of 
aberrant  relations  of  uric  acid ;  that  it  consists  in  something 
more  than  a  perversion  of  animal  chemistry ;  that  it  is  not,  by 
any  means,  to  be  explained  as  an  outcome  of  gastric  or  hepatic 
distemper ;  and  that  it  is  not  the  appanage  only  of  the  middle- 


8     A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT. 

aged  or  elderly  high-liver  and  intemperate  drinker,  because, 
as  is  well  known,  it  affects  also,  sometimes  in  early  life,  the 
high-thinker  and  the  laborious  bread-winner.  Without  doubt, 
while  accepting  all  (and  that  is  much)  that  it  is  good  for,  one 
is  impelled  to  look  beyond  what  may  be  termed  the  chemical 
pathogeny  of  gout.  The  researches  into  the  nature  and 
functions  of  the  nervous  system,  as  carried  out  during  the  past 
quarter  of  this  century,  come  to  our  aid  at  this  stage  of  our 
inquiry,  and,  amongst  these,  we  have  learned  two  main  and 
important  points  respecting  the  neuroses  in  general.  The 
first  is,  that  they  may  be  primary  or  central,  and  the  other  is, 
that  they  may  be  secondary  or  induced.  In  other  words,  it 
may  be  averred  that  a  neurosis  is  implanted,  or  a  tendency  to 
it  established,  and  this  shall  be  handed  down,  hereditarily 
passed  on,  and  thus,  a  diathetic  tendency  be  formed ;  or,  owing 
to  some  toxsemic  condition  or  blood-degeneration,  a  secondary 
or  induced  neurosis  may  be  established. 

I  shall  endeavour  to  sustain  the  neurotic  theory  of  gout  upon 
this  basis. 

Eepresenting  special  conditions,  or  rather  special  morbid 
modes  of  evolution,  of  nerve-force,  neuroses  are  implanted  in 
the  individual  as  a  part  of  his  intimate  nature.  They  belong 
to  the  individual,  and  are  characteristic  of  him  in  the  same 
degree  that  are  his  features  and  other  physiognomical  traits. 
An  implanted  neurosis  is,  as  it  were,  the  representative  of  a 
morbid  physiognomy  for  the  cerebro-spinal  axis.  A  neurosis, 
then,  is  a  peculiar  disposition,  or  tendency,  on  the  part  of  the 
nervous  system,  or  some  definite  tract  of  it,  towards  morbid 
evolution  or  manifestation  of  nerve-functions.  It  does  not 
necessitate  the  existence  of  any  coarse  disease,  directly  obvious 
to  the  eye,  but  it  is  a  more  or  less  abiding  condition,  ready  to 
come  into  action  upon  suitable  provocation. 

It  is  specially  characteristic  of  neuroses  that,  being  thus 
primarily  impressed  upon  an  individual,  they  tend  to  be 
transmitted  by  heredity.  It  has  been  alleged  that  the  female 
sex  is  more  neurotically  disposed  than  the  male  ;  but  facts 
do  not  support  this  opinion  thus  broadly  put  forth.  Certain 
neuroses  appear  to  prevail  with  greater  frequency  in  males, 
and  others  in  females ;  and  not  only  so,  but  in  the  case  of  those 


A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT.     9 

that  are  common  to  both  sexes,  the  manifestation  occurs  at 
different  epochs  of  life. 

Thus,  some  outbreaks  of  neurotic  disorders  are  seen  to  occur 
at  the  several  septennial  climacteric  periods,  at  the  times  of 
dentition,  puberty,  and  often  at  the  grand  climacteric.  In  this 
manner,  an  element  of  distinct  periodicity  attaches  to  neuroses 
in  general. 

Further,  a  most  marked  feature  in  all  neurotic  affections 
is  that  of  paroxysmal  tendency.  Thus,  there  is  the  abiding 
element,  with  proclivity  to  recurring  outbreak. 

Again,  it  is  certainly  known  that  a  law  of  alternation,  or 
substitution,  prevails  in  neuroses,  and  thus  we  meet  with 
certain  affections  in  the  parent  or  ancestors,  and  with  others, 
equally  neurotic,  in  the  collateral  relations  or  descendants. 
We  thus  have  to  deal  with  distinct  types  of  nervous  impres- 
sion. These  abiding  conditions  are  more  or  less  prone  to  be 
excited  into  activity  according  to  various  circumstances. 

It  is  not  difficult  to  understand  the  course  pursued  by  a 
neurotic  taint  once  laid  down  or  impressed  ;  but  it  is  not  so 
easy  to  conceive  the  original  implanting  of  such  a  morbid 
functional  tendency.  The  mischief,  however,  is  constantly 
originating  in  individuals,  and  as  constantly  undergoing 
further  development,  modification,  or  even  repression. 

Excessive  activity  of  the  nervous  system,  or  of  any  part  of 
it,  as  Laycock  has  shown,  becomes  a  highly-disposing  cause  of 
the  neuroses.  Habitual  or  prolonged  excess  comes  thus  to 
develop  hereditary  tendency.  Thus,  undue  mental  labour, 
gluttony,  alcoholic  intemperance,  debauchery,  and  other  indulged 
evil  propensities  in  the  parent,  come  to  be  developed  into  definite 
neurotic  taint  and  tendency  in  the  offspring.  Particular  examples 
of  this  are  not  far  to  seek,  and  amongst  them  comes  out  the  dis- 
order so  widely  and  variously  manifested  as  gout.  According 
to  this  view,  for  which  I  plead,  gout  appears  as  a  diathetic 
neurosis,  and  a  link  in  the  long  chain  of  its  phenomena,  so 
long  missing,  is  now  forthcoming. 

I  have  already  stated  that  there  is  clear  warrant  for  retaining, 
as  part  of  the  pathology  of  gout,  a  humoral  hypothesis,  and  it 
may  perhaps  be  applied  and  relegated  to  its  proper  place,  as 
follows.     Granting  that  gout  in  any  individual  is  the  outcome 


10    A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT. 

of  a  central  neurotic  taint,  we  have  the  ordinary  manifesta- 
tions of  it  more  or  less  severe.  This  we  may  term  primary  or 
central  gout.  The  tendency  may  be  transmitted  or  modified, 
or,  conceivably,  may  be  allowed  to  die  out. 

In  another  individual,  gout  may  "  grow  up "  where  pre- 
viously there  was  no  neurotic  taint  or  tendency.  A  patient 
is  commonly  said  to  earn  his  gout  by  high-living  and  over- 
indulgence of  appetites.  In  this  instance  a  morbid  blood- state 
is  induced ;  excess  of  uric  acid  is  generated,  and  hyperinosis 
supervenes. 

But  is  this  all  ?  Is  this  enough  to  generate  all  the 
phenomena  we  recognise  clinically  in  gouty  disease  ?  I 
believe  not.  We  are  compelled  at  this  point  to  widen  our 
view,  and  are  driven,  perforce,  to  invoke  the  operations  of  the 
nervous  system.  Having  arrived  thus  far  at  nothing  beyond 
a  special  toxtemia,  we  must  drop  humoral  pathology,  and  seek 
for  the  effects  of  the  blood-dyscrasia  upon  the  nerve-centres. 
And  we  have  full  warrant  for  this  course  in  contemplating  the 
analogy  of  other  toxaemic  states,  together  with  their  effects 
upon  the  nervous  system.  The  nutrition  of  this  system  is 
plainly  affected  by  morbid  blood-conditions,  and,  thus,  expres- 
sion is  given  to  such  poisoning  in  the  form  of  convulsion  and 
other  nervous  symptoms. 

I  believe,  then,  it  may  be  conceded  that  a  secondary  affection 
of  some  nerve-centre  occurs  as  a  consequence  of  the  altered 
blood-state  ah  intra,  and  that  thus  the  order  and  particular 
process  of  the  gouty  attack  is  evolved.  This  we  may  term 
secondary  or  acquired  gout.  A  diathetic  neurosis  is  thus 
impressed  upon  the  individual.1 

It  is  certainly  a  matter  of  much  interest  to  study  side  by 
side  with  gouty  processes  the  several  joint-affections,  or 
arthropathies,  which  have  come  to  be  regarded  of  late  as  of 
distinctly  spinal  or  otherwise  nervous  origin.  It  seems  impos- 
sible to  separate  gouty  arthritis  from  this  connection.  And 
if  it  be  conceded  that  this  particular  form,  which  is  but  one 

1  The  frequency  and  severity  of  gout  in  England  is  explicable  on  the  view  of 
the  impressed  neurosis.  The  habits  leading  to  gout, — high-living,  intemperance 
in  strong  drinks  (malt-liquors  and  wines),  along  with  much  mental  energy,  have 
certainly  prevailed  more,  and  amongst  larger  classes,  in  England  than  in  either 
Scotland  or  Ireland. 


A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT.    11 

of  many  others,  is  truly  and  directly  dependent  upon  nerve- 
influence,  the  greatest  part  of  the  difficulty  in  establishing  a 
neurotic  theory  of  gout  is  forthwith  removed.  I  suppose  no 
greater  obstacle  has  stood  in  the  way  of  the  acceptance  more 
generally  of  a  nervous  theory  of  this  malady,  than  the  impossi- 
bility hitherto  of  connecting  arthritic  disposition  with  any 
form  of  neurosis.  So  many  of  the  other,  and  less  obvious, 
manifestations  of  gout  are  plainly  dependent  on  nervous 
influence,  that  the  whole  phenomena  now  appear  to  fall  more 
naturally  into  their  places. 

It  is,  however,  only  right  to  mention  here  that  thoughtful 
physicians  have  long  ere  now  conceived  the  special  action  of 
nerve-influence  on  joints,  and  of  arthritic  affection  on  nerve- 
centre.1  The  relation  sometimes  existing  between  rheumatic 
fever  and  chorea  is  an  example  in  point,  as  Dr.  Liveing  has 
shown. 

Much  light  has  been  thrown  of  late  upon  spinal  arthro- 
pathies by  the  researches  of  Charcot,  Ball,  Weir  Mitchell,  and 
of  Dr.  Ord.  The  latter  has  recently  contended  for  a  more 
scientific  revision  of  our  present  views  upon  the  pathology  of 
osteo-arthritis  or  rheumatic  gout. 

Without  elaborate  reasoning,  Dr.  Noel  Gueneau  de  Mussy,  of 
Paris,  expressed,  some  years  ago,  his  opinion  that  the  latter 
affection  was  related  to  gout,  as  a  sort  of  cousin,  but  without 
in  any  way  holding  the  view  that  the  disorder  was  a  compound 
of  rheumatism  and  gout.2 

Dr.  Ord's  views  are  not  only  eminently  ingenious,  but 
they  accord  remarkably  with  well-observed  clinical  facts,  not 
hitherto  correlated. 

As  Sir  James  Paget  has  remarked,  the  changes  in  the  nerve- 
centres  which  determine  the  locality  of  the  gouty  process,  are 
a  part  of  the  pathology  of  gout  which  is  not  yet  clinical. 
They  are,  therefore,  no  more  than  speculative  at  present,  but 
we  gain  much  from  the  prosecution  of  an  inquiry  in  this 
direction. 

With   respect   to   the    particular   locality   affected   in   the 

1  Liveing,  op.  cit.  p.  247.  Weir  Mitchell,  Charcot,  &c. 

2  Mr.  Hutchinson  believed  in  a  "basic  diathesis,"  for  both  gout  and  osteo- 
arthritis. 


12    A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT. 

arthropathy  of  locomotor  ataxia  there  is  some  discrepancy  of 
opinion.  Charcot  has  declared  for  implication  of  the  anterior 
cornua  of  the  spinal  chord.  Dr.  Buzzard,  however,  has  not 
confirmed  this  opinion,  and,  guided  by  the  noteworthy  frequent 
association  of  gastric  crises  with  these  joint-affections  in  this 
malady,  as  previously  observed  by  Dr.  Ball,1  has  suggested 
a  sclerosing  lesion,  involving  the  roots  of  the  vagus  in  the 
medulla  oblongata,  in  close  relation  to  some  trophic  centre 
that  may  be  localised,  there,  presiding  over  the  osseous  and 
articular  systems.  And  he  further  indicates  the  bond  that 
may  thus  exist  between  implication  of  joints  and  such  meta- 
stasis as  may  occur  to  the  heart  in  rheumatic  fever :  also  the 
occurrence  of  hyperpyrexia,  which  is  sometimes  present  in 
such  cases.  We  have  yet  to  seek  for  this  hypothetical  nutrient 
centre  for  joints,  but  in  the  meantime  we  are  fairly  warranted 
in  widening  our  view,  and  in  directing  attention  to  the  high 
significance  of  predicating  such  a  trophic  centre. 

"  Discovery  by  true  analogies  is  always  progressive,  .  .  . 
one  analogy  leads  on  to  another  investigation  and  arrange- 
ment of  phenomena,  and  another  analogy."  2 

It  remains  now  to  be  shown,  more  in  detail,  how  the  pheno- 
mena of  gout  conform  to  the  recognised  manifestations  of  the 
neuroses  in  general. 

It  can  be  shown,  I  believe,  that  the  plea  for  the  neurotic 
element  in  true  gout  is  not  difficult  to  establish. 

First,  there  is  to  be  considered  the  marked  tendency  of  gout 
to  be  hereditarily  transmitted.  This  is  notorious.  The  dis- 
order may  pass  from  either  parent,  and  may  be  mingled  with 
other  taints  and  tendencies  passed  on  from  the  progenitors. 
The  outbreak  may  occur  in  slight  or  in  graver  degrees,  and 
may  be  deferred,  overtly,  till  even  the  thirteenth  climacteric 
period.  Thus,  the  first  plain  attacks  of  gout  may  not  appear 
till  the  patient  is  sixty  or  over  ninety  years  of  age.  In 
all  such  cases,  however,  I  am  convinced  that  many  minor 
tokens  of  the  disorder  have  been  overlooked  in  previous  years, 
all  of  which  are  sufficiently  obvious  to  the  trained  clinical  eye. 


'Med.  Times  and  Gazette,'  vol.  ii.  (1868);  vol.  ii.  (1869),  p.  498. 
Laycock,  op.  cit.  190. 


A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT.    13 

As  a  rule,  the  manifestations  are  prone  to  occur  at  definite  ages 
in  each  sex,  most  commonly  in  the  fourth  decade  in  men,  and 
in  the  fifth  in  women.  My  own  experience  seems  to  show  that 
gout  is  increasingly  frequent  in  men  early  in  the  third  decade. 

Certain  peculiarities  attending  gouty  transmission  are 
deserving  of  study.  Mr.  Hutchinson  has  called  attention  to 
one  of  these  in  a  suggestive  lecture  published  four  years  ago.1 
He  expresses  his  belief  that  what  is  transmitted  is  not  the 
active  gouty  dyscrasia  itself,  but  rather  a  susceptibility  to 
the  influence  of  certain  exciting  causes,  together  with  some 
peculiarly  disordered  condition  of  the  assimilating  and  excre- 
tory viscera,  which  renders  them  unable  to  deal  with  particular 
articles  of  food.  Now,  this  special  susceptibility  to  definite 
exciting  factors  is  neither  more  nor  less  than  a  nervous  peculi- 
arity, of  which  the  chief  character  is  its  liability  to  break 
away  in  certain  morbid  directions, — its  instability,  in  short. 
This  is,  I  submit,  the  gouty  neurosis.  Mr.  Hutchinson  further 
believes  that  gout  is  wont  to  show  itself  with  greater  frequency 
and  in  more  marked  form  in  the  younger  than  in  the  older 
members  of  a  gouty  family,  the  diathesis  strengthening  in 
the  parent  with  advancing  years.  I  think  I  can  confirm 
this  observation.2  Resemblance  to  the  gouty  parent  has  been 
specially  recognised  in  those  of  the  offspring  most  distinctly 
affected.3  In  other  members  of  the  family  the  tokens  of  gout 
may  be  present,  but  less  marked.  These  facts  are,  of  course, 
in  accordance  with  ordinary  laws  of  hereditary  transmission. 
Dr.  Wickham  Legg  has  called  attention  to  the  fact  that  gout, 
like  haemophilia,  pseudo-hypertrophic  paralysis  of  Duchenne, 
and  some  other  affections,  is  not  unfrequently  found  to  be 
transmitted  by  the  female  line,  although  especially  manifested 
in  males,  the  mothers  themselves  being  unaffected. 

A  noteworthy  feature  in  gouty  ailments  is  their  sudden 
supervention.  As  in  epilepsy,  not  uncommonly,  the  patient 
often  feels  remarkably  well,  and  realises  his  sense  of  Men  etre, 
before  the  outbreak  suddenly  takes  place.     This  euphoria,  or 

«  'Medical  Times  and  Gazette,'  vol.  i.  p  543  (1876). 

2  Cases  illustrating  this  are  given  by  Mr.  Spencer  Wells,  op.  cit.  p.  18. 

3  '  Medical  Notes  and  Reflections  on  Hereditary  Disease*'  Sir  Henry  Holland, 
Bt.,  M.D.,  F.R.S.     Edit,  3  (1855),  p.  29.  ■ 


14    A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT. 

delusive  corporeal  satisfaction,  is  itself  a  nervous  derangement. 
Explosiveness  is  a  distinct  feature  in  several  of  the  neuroses, 
and  attaches  to  such  ailments  as  angina  pectoris,  asthma, 
epilepsy,  and  various  neuralgiae. 

The  time  of  the  occurrence  of  the  attack  is  also  strongly 
marked.  The  majority  of  the  outbreaks  take  place  in  the 
early  morning.  This  is  true  both  of  grave  and  classical  cases, 
and  also  of  many  of  the  minor  forms  of  gouty  trouble.  The 
same  thing  is  met  with  in  asthma,  neuralgia,  and  in  epilepsy. 
The  pyrexia  proper  to  acute  gout  is  paroxysmal,  with  re- 
missions, and  the  pain  of  gout  is  likewise  paroxysmal.  One 
is  here  reminded  of  the  influence  of  marsh-poison  upon  the 
nervous  centres. 

This  paroxysmal,  no  less  than  the  periodic,  element  in  gout, 
stamps  a  nervous  character  upon  the  malady,  and  binds  it  in 
alliance  with  other  neuroses.1 

An  important  connection  of  the  same  kind  is  seen  in  the 
unquestionable  commingling  of  gout  with  other  well-recognised 
neuroses.  Thus,  hemicrania  is  sometimes  distinctly  a  mani- 
festation of  gout  in  both  sexes,  and  may  be  the  form  of  neurosis 
impressed  upon  an  individual  whose  parent  was  gouty,  or 
may  itself  alternate  with  gouty  arthritic  attacks  in  the  same 
person.2 

It  is  not  far  to  seek  for  an  allied  condition  of  trophical 
lesion  in  herpes  zoster,  itself  the  outcome  of  disordered 
innervation. 

The  doctrine  of  metastasis  must  next  be  considered  in 
relation  to  gout.  The  humoralist  seeks  to  explain  this  clinical 
fact  upon  his  theory,  but  such  is  manifestly  insufficient  to 
account  for  the  phenomena.  It  must  be  conceded  that  some 
nervous  law  regulates  the  occurrence  of  shifting  inflammation. 
It  has  been  supposed  to  be  due  to  reflex  influence.  Some 
distinct  predisposition  to  take  on  the  morbid  action  exists  in 
the  part  selected  apparently  by  caprice.  The  same  class  of 
tissue  is  apt  to  suffer.  Thus,  the  gouty  or  rheumatic  process 
flies  from  joint  to  joint,  or,  as  in  gouty  phlebitis,  from  vein  to 

1  Vide  Scudamove,  op.  cit.  p.  152. 

2  8talil,  op.  cit.  §  xxxvi.    Trousseau,  '  Clin.  Me'd.'     Liveing,  op.  cit.,  &c.     Sir 
II.  Holland,  op.  cit,  '  Relation  of  Asthma  to  Gout,'  p.  30. 


A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT.    15 

vein,  sometimes  symmetrically,  but  not  always.  The  serous 
and  fibro-serous  structures  suffer  especially,  but  also  mucous 
surfaces.  Laycock  has  shown  how  these  several  tissues  are 
related  embryologically,  and  are  thus  prone  to  suffer  in 
common  when  diathetically  impressed.1 

Localised  trophical  changes  follow  locally  acting  causes  of 
depressed  nervous  power.  Thus,  impairment  of  certain  centres 
may  lead  to  the  specific  nutritional  changes  witnessed  in 
metastases,  and  thus  the  apparent  capriciousness  is  explained 
in  this  process. 

Amongst  the  nervous  symptoms  of  gout  must  next  be 
considered  the  occurrence  of  certain  sensory  perversions,  such 
as  tingling  and  numbness  of  the  fingers  and  toes,  sensations 
of  heat  in  the  palms,  thighs,  and  soles  (paresthesia),  and 
tickling  in  the  throat.  As  pointed  out  by  Sir  James  Paget, 
"  gout  affects  the  sensory  much  more  than  the  motor  elements 
of  the  nervous  system,"  and  he  remarks,  too,  that  the  pain  of 
acute  gout  is  seemingly  out  of  all  proportion  to  the  amount  of 
inflammatory  process  in  the  affected  part.  So,  too,  all  other 
disorders,  modified  by  gout,  seem  to  be  especially  painful,  for 
example  cancer,  as  pointed  out  also  by  Paget. 

Grinding  of  the  teeth  is  met  with  in  the  gouty.  Graves 
first  observed  this.2  Garrod  has  not  met  with  it.  Dr.  Donkin 
has  lately  recorded  cases  associated  with  somnambulism,3  and 
I  have  intimate  knowledge  of  two  others  in  which  the  same 
phenomena  are  manifested — the  grinding  of  teeth  and  som- 
nambulism in  a  sister,  and  the  talking  in  sleep  in  the  brother. 
The  maternal  grandfather  and  the  mother  are  distinctly  gouty. 
Cramps  in  the  muscles  of  the  legs,  and  priapism,  are  amongst 
nocturnal  manifestations  in  the  gouty.  Of  insomnia,  due  to 
gout,  there  is  much  to  say.  It  was  originally  noted  by  Cullen, 
and  it  conforms  remarkably  with  iother  periodic  neurosal 
phenomena.4 

Gouty  neuralgia  is  largely  recognised,  and  is  known  to  be 
both  severe  and  prone  to  recur.     It  is  frequently  occipital, 

1  Op.  cit.,  p.  19G. 

2  'Clin.  Med.,'  p.  351  (18G4  edit.). 

*  'Brit.  Med.  Journal,'  Feb.  21,  1880,  p.  270. 

4  Vide  Author's  paper,  '  St.  Barth.  Hosp.  Reports,'  jam  cit.,  p.  105. 


16    A  PLEA  FOR  THE  NEUROTIC  THEORY  OP  GOUT. 

and  is  met  with  in  the  heel,  tongue,  breast,  aud  more  often  in 
the  great  sciatic  nerve.  One  proof,  amongst  others,  of  the 
truly  gouty  nature  of  these  is  gained  from  the  fact  that  they 
yield  most  readily  to  anti-gouty  medication,  and  another 
lies  in  the  frequency  with  which  they  are  provoked  by  condi- 
tions which  elicit  other  gouty  processes. 

Amongst  the  strongest  evidences  of  gout  depending  upon 
nervous  influences,  are  the  unquestionable  facts  bearing  upon 
the  induction  of  its  attacks. 

The  influence  of  many  of  the  existing  causes  of  gouty 
paroxysms  illustrates  well  the  explosive  character  of  the 
malady.  As  Sydenham  expresses  it,  before  the  onset  of  an 
attack,  "  totum  corpus  est  podagra."  The  precipitation  of 
the  seizure  sometimes  ensues  almost  immediately  upon  the 
provoking  cause.  In  a  large  number  of  instances,  the  latter  is 
of  a  nature  to  depress  nervous  power.  Thus,  unwonted  muscular 
energy,  prolonged  exercise,  stirring  emotions,  fright,  undue 
excitement,  venereal  excess,  rage,  worry,  and  vexation,  are  all 
excitors  of  gouty  paroxysm.  So,  too,  sudden  shock  to  the 
body,  as  from  injuries  and  surgical  operations,  will  evoke 
gout.  Dietetic  errors  are  well  recognised  as  factors ;  thus,  a 
full  meal,  and  excess,  or  mixing,  of  strong  liquors,  will  act 
in  upsetting  the  equilibrium  of  a  quiescent  gouty  habit.  It 
will  be  conceded  that  many  of  the  causes  just  enumerated  are 
equally  potent  to  elicit  manifestations  of  other  neuroses,  such 
as  epilepsy,  asthma,  hemicrania,  and  angina  pectoris.  The 
provoking  agency,  however,  need  not  always  be  primarily 
exhausting.  In  proof  of  this,  the  outbreaks  of  gout  following 
hydropathic  treatment,  internally  or  externally,  may  be  in- 
stanced, and,  indeed,  the  causal  element  need  only  be  such 
as  shall  induce  some  change  in  the  acquired  vital  habits. 

Thus  it  is,  that  the  subjects  of  the  neuroses  hold  much  of 
their  comfort  in  life  by  following  a  very  equable  routine. 
They  are  prone  to  give  way  under  any  extraordinary  pressure. 

These  considerations  explain,  in  part,  why  men  are  more 
liable  to  gout  than  women.  They  carry  on  the  world's  rough 
work;  are  engaged  in  more  exciting  occupations,  and  have 
commonly  the  greater  burden  of  anxiety  to  bear. 

The   more    sedentary  the    occupation,   the   more   profound 


A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT.    17 

the  mind-working,  and  the  more  intense  the  strain  of  life,  the 
greater  the  tendency  to  nervous  depression,  and  to  the  peculiar 
form  of  its  expression  in  gout.  If  to  such  habits  be  added 
high-living,  as  often  occurs  in  the  cases  of  eminent  statesmen, 
lawyers,  and  speculators,  no  link  is  wanting  in  the  chain  of 
causation,  and  all  the  elements  for  gout  are  present. 

Climatic  influence  is  important  amongst  these  agencies. 
The  dull  and  "shifty"  weather,  and  the  cold  east  winds  of 
northern  latitudes  are  certainly  bad  for  gout.  The  nervous 
depression  ensuing  upon  months  of  sunless  skies — negation  of 
light  powerfully  lowering  nervous  tone — is  too  little  regarded 
as  an  element  of  devitalisation  in  England.  The  cutaneous 
eliminant  power  is  checked,  and  so,  aberrant  chemical  rela- 
tions are  apt  to  be  determined  in  any  parts  specially  prone  to 
gouty  invasion. 

The  same  mal-determination  ensues  upon  the  suppression  of 
various  discharges,  whether  from  the  uterus,  from  haemor- 
rhoids, or  other  sources. 

The  mental  condition  of  the  goutily-disposed  is  a  subject 
worthy  of  attention  in  relation  to  the  pathology  of  the  ailment. 

Hypochondriasis  has  long  been  associated  with  gouty  taint. 
It  commonly  precedes  an  outbreak,  and  disappears  subse- 
quently. A  tendency  to  sighing  has  also  been  observed,  and 
is  a  plain  indication  of  nervous  exhaustion.  Hysteria  has  also 
been  observed  to  precede  gouty  attacks  in  women,  and  to 
disappear  with  the  onset  of  articular  symptoms. l 

Irritability  of  temper  is  a  proverbial  condition  in  the  gouty, 
and  furious  outbursts  of  this  kind  appear  to  be,  at  times,  a 
metamorphic  substitution  for  a  more  overt  and  regular  attack. 
It  is  important  to  know  that  many  of  the  minor,  but  none  the 
less  well-marked,  phases  of  gouty  paroxysm  are  in  no  degree 
arthropathic.  Much  error  in  diagnosis  has  arisen  from  taking 
no  heed  of  any  but  articular  symptoms  when  searching  for 
gouty  tokens  in  a  given  case.  These  less  classical  attacks 
very  commonly  precede  the  onset  of  typical  ones  at  a  later 
period  in  life. 

The  necessity  for  prompt  recognition   of  these  less  well- 

1  'On  the  relations  between  Gout  and  Hysteria,'  vide  'Treatise  on  the 
Nervous  Diseases  of  Women'  (p.  163).    By  T.  Laycock.     1840. 

VOL.   III.  0 


18    A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT. 

expressed  symptoms  is  obvious,  if  good  treatment  is  to  be 
applied. 

Epilepsy  has  been  known  to  disappear  on  the  supervention 
of  gout. 

Sensations  of  giddiness  and  dimness  of  vision,  not  uncommon 
in  the  gouty,  are  noteworthy  in  relation  to  nervous  symptoma- 
tology.1 So,  too,  the  disturbances  of  the  cardiac  rhythm,  and 
the  co-existent  (neurotic)  vascular  throbbings  which  are  some- 
times met  with.  The  cardiac  irregularity  has  been  noted  to 
cease  with  the  induction  of  a  regular  attack.  Dysphagia  was 
noted  in  connection  with  gout  by  no  less  careful  an  observer 
than  the  late  Dr.  Brinton. 

A  consideration  of  the  effects  of  lead-impregnation  in  relation 
to  gout,  and  of  the  certain  liability  of  the  gouty  to  be  more 
readily  than  others  influenced  by  lead,  leads  to  the  belief  that 
the  nervous  system  is  specially  implicated  in  these  relations. 
The  fact  is,  that  the  blood  is  imperfectly  freed  from  uric  acid 
in  cases  of  lead-poisoning,  and  that  gout  is  thus  quickly  evoked. 
Dr.  Garrod  has  fully  established  these  facts,  and  all  physicians 
now  recognise  them.  The  lead-influence,  clearly  through 
nervous  agency,  induces  the  measure  of  renal  inadequacy 
which  is,  probably  with  correctness,  acknowledged  as  a  factor 
in  gout.  And  the  knowledge  that  this  metal  is  capable  of 
setting  up  special  paralysis,  epilepsy,  coma,  and  other  cerebral 
phenomena,  is  of  the  largest  interest  in  relation  to  this  subject. 

I  now  approach  a  point  in  connection  with  the  whole  patho- 
logy of  gout  which  merits  much  consideration.  The  connection 
of  diabetes  with  gout  has  been  recognised  for  some  years. 

I  object  to  the  term  diabetes  as  applied  to  the  special  form 
of  glycosuria  associated  with  gout.  The  disorder  is  met  with 
in  certain  members  of  gouty  families,  some  having  regular 
gout,  and  others  manifesting  less  regular  gout,  or  this  alter- 
nating with  glycosuria.  I  believe  that  many  cases  of  tem- 
porary glycosuria  are  due  to  gouty  conditions.  The  fleeting 
presence  of  glucose  in  the  urine  of  many  elderly  persons  may 
be  thus  explained.  It  has  long  been  recognised  that  such  an 
affection,  which,  in  many  instances,  is  undeserving  of  the  name 

1  Trousseau,  Murchison,  Paget,  op.  cit.,  H.  Mayo,  F.R.S.,  « Philosophy  of 
Living,'  p.  24  (1837). 


A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT.    19 

diabetes  mellitus,  for  the  simple  reason  that  there  is  no  diabetes 
in  the  strict  sense  of  the  term,  is  not  really  a  grave  one.  The 
presence  of  glucose  is  found  to  alternate  with  that  of  uric  acid. 
In  the  aged  but  little  importance  should  be  attached  to  the 
symptom.  Charcot  testified  to  this,  some  years  ago,  in  his 
excellent  lectures  on  the  maladies  of  old  people,  his  experience 
being  gathered  at  that  fertile  school  of  study — the  Salpetriere. 
In  persons  under  forty  years  of  age,  however,  glycosuria,  even 
of  gouty  origin,  is  a  most  grave  matter,  and  merits  the  closest 
attention,  since  it  may  eventuate  in  confirmed  diabetes.  It  is 
the  rule  to  find  that  the  quantity  of  urine  passed  is  not  much, 
if  at  all,  above  the  normal,  but  the  specific  gravity  may  range 
from  1*035  to  1'050.  An  anti-gouty  treatment  is  called  for, 
for  the  glucose  may  otherwise  only  give  place  to  uric  acid  or 
increased  azoturia,  and  the  gouty  habit  has  rather  to  be 
attacked  than  the  glycosuria. 

Dr.  Lauder  Brunton  has  called  attention  to  this  class  of  cases.1 
The  alliances  of  gout  and  diabetes  are  sufficiently  intimate. 
In  both  the  doctrine  of  heredity  applies,  and  the  nervous 
system  is  involved.  The  same  habits  lead  to  each,  the  same 
classes  of  person  are  affected,  and  the  same  exciting  causes  are 
potent  to  evoke  both.  A  consideration  of  these  facts  naturally 
leads  to  the  belief  that  the  portions  of  the  nervous  system 
involved  in  each  cannot  be  far  apart  from  one  another.  The 
medulla  oblongata,  the  sympathetic  and  splanchnic  nerves 
have  been  found  chiefly  affected,  and  the  spinal  chord  likewise 
in  some  instances.  The  point  for  the  diabetic  puncture  in 
the  medulla  is  believed  by  physiologists  to  correspond  to  the 
vaso-motor  centre  in  the  same  structure. 

Guided  by  these  facts,  and  by  the  knowledge  that  the  glyco- 
genic function  of  the  liver  is  under  nervous  influence,  by  the 
advancing  theories  which  refer  special  arthropathies  like- 
wise to  the  same  influence,  and  bearing  in  mind  Dr.  Buzzard's 
views,  previously  stated,  in  connection  with  the  gastric  crises 
so  commonly  associated  with  the  arthritis  of  loco-motor  ataxia, 
I  come  to  the  conclusion  that  the  portion  of  the  nervous  system 
which  is  specially  predisposed  to  the  irregular  mode  of  action 
known  as  gout,  has  its  seat  or  centre  in  the  medulla  oblongata. 

1  Art.  "Diabetes  Mellitus,"  Reynolds'  «Syst.  of  Med.,'  vol.  v.  p.  381  (1879). 

c  2 


20     A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT. 

A  point  of  difference  between  the  arthritic  affections  which 
are  now  referred  to  nervous  influence,  and  those  manifested  in 
gout,  is  found  in  the  fact,  that  the  latter  appears  to  have  an 
elective  affinity,  often  unilateral  at  first,  for  the  smaller  joints, 
especially  that  of  the  big  toe,  while  most  of  the  others  influ- 
ence the  larger  ones.  Herein,  perhaps,  lies  part  of  the  speci- 
ficity of  gout. 

The  trophical  results  of  the  latter  are  seen  impressed 
upon  the  physiognomy,  and  upon  certain  tissues,  in  a  manner 
extremely  definite  and  characteristic. 

Thus,  are  found  the  large  head,  the  thick  hair,  with  ten- 
dency to  early  greyness,  the  large,  full  veins,  the  long  uvula, 
the  soft,  smooth  skin,  the  thickened  extremity  of  the  nose,  and 
the  lineated,  brittle  nails. 

Lastly,  I  may  add  an  argument  in  favour  of  the  theory, 
adduced  in  this  essay,  from  the  therapeutical  side. 

The  universally  acknowledged  specific  action  of  colchicum 
in  gout  is  known,  owing  to  Garrod's  researches,  to  be  due  to 
no  power  which  it  possesses  of  causing  elimination  of  uric  acid. 
Gouty  inflammation  is  therefore  influenced  by  it  without  refe- 
rence to  the  secondary  aberrant  relations  of  uric  acid.  The 
active  principle,  or  alkaloid,  of  the  drug  colchicia,  is  a  member 
of  a  nitrogenised  group  of  bodies  to  which  veratria,  strychnia, 
quinia,  and  morphia  have  close  chemical  alliance.1  They  all 
powerfully  affect  the  nervous  system.  Colchicum  acts  very 
promptly,  and  affords  often  decided  relief  to  the  intolerable 
pain  of  the  gouty  process.  When  taken  in  health,  in  small  doses, 
Dr.  Meldon  and  others  have  found  that  it  induces  a  general 
glow  at  the  surface  of  the  body,  diaphoresis,  throbbing  of 
the  blood-vessels  and  palpitation.  Subsequently,  there  is  re- 
duction in  the  force  and  frequency  of  the  pulse.  Dr.  Meldon 
observed  in  his  own  case  an  invigoration  of  his  mental  energies. 
In  larger  doses,  the  effects  are  most  marked  along  the  whole 
tract  supplied  by  the  vagus,  and  thus,  cardio-vascular,  gastric 
and  enteric  symptoms  ensue. 

The  peculiar  benefit  derived  from  this  drug  is  not  secured 
in  any  other  form  of  inflammation,  and  thus   it  is  plainly 

1  Vide  'Lectures  on  Pathology  and  Therapeutics.'  (London,  1867;  p.  137.) 
H.  Bence  Jones,  M.D.,  F.R.S. 


A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT.    21 

specific.  Its  cherished  action  is  doubtless  exerted  upon  the 
vaso-motor  nerves. 

The  manifestly  good  influence  of  all  agencies  which  cheer- 
fully inspire  the  mental  condition  in  the  goutily-disposed, 
must  not  be  omitted  from  consideration  amongst  the  juvantia 
both  of  prevention  and  cure. 

The  points  in  this  thesis  which  I  have  endeavoured  to 
sustain,  I  now  place  categorically  under  the  following  heads. 

First. — I  contend  that  the  diseased  conditions  which  are 
recognised  as  of  unequivocal  gouty  nature,  are  primarily 
dependent  upon  a  functional  disorder  of  a  definite  tract 
of  the  nervous  system,  and  that,  thus,  gout  is  a  primary 
neurosis. 

Secondly. — That  there  is  much  in  the  nature  of  the  malady 
itself,  and  much  evidence  forthcoming  by  way  of  analogy,  to 
warrant  the  conjecture  that  the  portion  of  the  nervous  system 
specially  involved  is  situate  in  some  part  of  the  medulla 
oblongata,  where,  possibly,  may  be  placed  a  trophic  centre  for 
the  joints. 

Thirdly. — That  the  gouty  neurosis  may,  like  others,  be 
acquired,  intensified,  and  transmitted,  also,  that  it  may  be 
modified  variously,  and  commingled  with  other  neuroses  ;  that 
it  may  suffer  metamorphic  transformations,  or  be  altogether 
repressed. 

Fourthly. — That  this  diathetic  neurosis  imposes  its  type 
upon  the  affected  individual  in  definite  nutritional  modes, 
affecting  the  assimilating  and  excreting  powers,  exhibiting 
marked  peculiarities  in  nervous  impressibility,  and  determi- 
ning, in  more  or  less  degree,  a  physiognomy  of  the  gouty. 

Fifthly. — That  a  large  part  of  the  phenomena  known  as 
gouty,  are  due  to  perverted  relations  of  uric  acid  and  sodium 
salts  in  the  economy,  resulting  from  the  morbid  peculiarities 
mentioned  under  the  last  head.  Thus,  there  is  excess  of  urate 
of  soda  in  the  blood  before,  and  during,  gouty  explosive  mani- 
festation, and  there  is  determination  (by  nervous  influence,  in 
all  probability)  either  of  this  salt  to  the  affected  part  (Garrod),1 
or  there  is  a  too  free  formation  of  it  at  these  inflammatory 

1  Op.  cit. 


22    A  PLEA  FOR  THE  NEUROTIC  THEORY  OF  GOUT. 

points,  whence  it  deposited  locally,  and  also  set  free  into  the 
circulation  (Ord). 

The  renal  excretory  power  for  uric  acid  appears  to  be  tem- 
porarily inhibited  as  part  of  the  process  of  gouty  paroxysm. 
This  measure  of  renal  inadequacy  would  appear  to  prevail  in 
varying  degree  as  a  part  of  the  specific  neurosal  disorder.  In 
chronic  gout,  when  structural  disease  has  occurred,  either 
tubal,  with  deposition  of  urate  of  soda,  or  interstitial,  with 
shrinking  of  the  organs,  the  renal  inadequacy  may  admit 
of  more  mechanical  explanation. 

Sixthly. — That  in  Primary,  or  inherited,  Gout,  the  toxaemia 
is  dependent  on  the  gouty  neurosis  ;  is  the  outcome,  in  what- 
ever degree,  of  it,  and  is  therefore  a  secondary  manifestation. 

Seventhly. — That,  in  what  I  term  Secondary,  or  acquired, 
Gout,  the  toxaemia  is  directly  induced  by  such  habits  as  over- 
load the  digestive  and  excretory  organs,  and  constantly  pre- 
vent complete  secondary  disposal  of  nutritional  elements  of 
food  ;  that  if,  together  with  such  toxaemia,  distinctly  depress- 
ing and  exhausting  agencies,  affecting  the  nervous  system, 
come  into  operation,  the  special  neurotic  manifestations  of  the 
gouty  diathesis  will  occur,  and  be  impressed  more  or  less  deeply 
upon  the  individual  and  his  offspring. 

Eighthly. — That  this  theory  of  gout,  better  than  any  other, 
correlates  all  the  known  factors  concerned  in  the  production 
of  the  varied  symptoms  of  the  malady  ;  and  while  it  displaces 
its  humoral  pathology  from  the  preeminence  it  has  so  long 
occupied,  it  takes  full  cognizance  of  it,  and  seeks  to  place  it 
in  a  clearer  relation  to  the  phenomena  of  the  disease. 

Ninthly. — That  if  it  be  desirable  to  refer  various  maladies 
to  their  distinct  place  in  pathology,  without  reference  merely 
to  their  chemistry,  histology,  or  neurology,  the  affection  known 
as  gout  may  perhaps  most  correctly  be  relegated,  along  with 
some  others,  to  a  class  of  diseases  which  may  be  termed  neuro- 
humoral. 

Tenthly. — An  argument  is  adduced  from  thejuvantia  afforded 
by  colchicum,  in  favour  of  the  theory  which  has  been  set  forth. 


THE   CONDITIONS   OF   THE   UNIPOLAE  STIMULA- 
TION IN  PHYSIOLOGY  AND  THEEAPEUTICS. 

BY   A.   DE   WATTEVILLE, 

Assistant-Physician  to  the  Hospital  for  Epilepsy  and  Paralysis,  Regent's  Park. 

By  electrotonus  is  meant  that  condition  of  altered  irritability 
of  a  nerve  which  is  produced  by  the  flow  through  it  of  a 
current  of  electricity ;  and  this  altered  irritability  manifests 
itself  by  increased  or  diminished  reaction  of  the  nerve  to 
the  various  stimuli,  whether  mechanical,  physical,  or  chemical, 
which  may  be  applied  to  it. 

Du  Bois  Keymond,  who  introduced  this  word  in  physiology,1 
at  first  implied  by  it  merely  the  changes  in  the  electromotive 
manifestations  of  the  nerve  which  accompany  the  changes 
in  its  irritability.  A  clear  recognition  of  the  latter,  says 
Hermann,2  does  not  occur  in  any  of  the  older  physiologists, 
nor  in  Du  Bois  Keymond's  great  work.  Valentin3  was  the 
first  to  show  that  the  polarised  portion  of  the  nerve  does  not 
readily  transmit  impulses  from  above ;  and  that  the  irrita- 
bility of  the  part  below  it  is  diminished  when  the  polarising 
current  is  centripetal,  or  ascending.  Eckhard4  observed  that 
when  the  current  is  descending,  an  opposite  condition  of 
augmented  irritability  below  the  polarised  portion  existed. 
Hence  he  formulated  as  a  general  law  that  irritability  is 
increased  beyond  the  kathode,  or  negative  pole ;  diminished 
beyond  the  anode,  or  positive  pole. 

Pfluger,  by  a  series  of  admirable  experiments,  eliminated  all 
the  sources  of  error  which  beset  this  difficult  field  of  inquiry, 
and  resolved  all  the  phenomena  into  his  dictum : — The  irri- 

1  '  Untersuelmngen  iiber  thicrisehe  Elektricit'at,'  1848,  1849. 

2  '  Handbuch  ck-r  Physiologie,'  vol.  ii.  part  i.  p.  41,  1879. 

3  ■  Lehrbuch  dcr  Physiologic,'  2nd  Ed.,  1848. 

4  '  Beitiago  zur  Anatomio  und  Pbysiologie,'  1855. 


24        CONDITIONS  OF   THE   UNIPOLAR  STIMULATION 

tability  is  increased  on  either  side  of  the  negative  electrode, 
diminished  on  either  side  of  the  positive.  Or,  in  other  words, 
the  region  of  the  kathode  is  thrown  into  a  state  of  katelectro- 
tonus,  that  of  the  anode  of  anelectrotonus.  In  the  intra-polar 
region  the  two  zones  meet  at  a  point  of  indifference,  where 
irritability  remains  normal.  This  point  is  the  nearer  to  the 
kathode  the  stronger  the  current,  and  vice  versa. 

Whenever  a  galvanic  current  of  sufficient  strength  is  made 
or  broken  through  a  portion  of  a  motor-nerve,  a  contraction  in 
the  muscle  occurs.  It  was  one  of  the  earliest  observations 
made  that  a  contraction  appears  earlier  (i.  e.  with  a  weaker 
current)  when  the  current  is  descending  (i.  e.  with  the  kathode 
peripherally  and  the  anode  centrally  placed)  than  under  the 
opposite  conditions  (Pfaff,  in  1795).  Eitter  (1798),  and  Nobili 
(1829),  with  a  host  of  other  observers,  confirmed  this  fact,  and 
elaborated  what  are  known  as  "  laws  of  contractions ; "  that  is, 
tables  of  the  reactions  which  the  exsected  nerve  yields  to  make 
and  break  off  the  ascending  and  descending  currents,  at  diffe- 
rent stages  of  its  diminishing  vitality.  That  such  researches 
must  have  been  limited  is  made  at  once  evident  by  the  con- 
sideration that  the  first  constant  galvanic  element  was  invented 
in  1836  by  Daniell.  Yet  on  the  whole  it  is  possible  to  recon- 
cile the  main  results "  obtained  up  to  the  time  of  Du  Bois 
Reymond,1  with  those  of  Heidenhain,2  who  substituted  "  stages 
of  current  strength  "  for  the  "  stages  of  irritability  "  of  his  pre- 
decessors. But  it  would  be  transgressing  our  present  limits  to 
delay  on  these  topics,  and  we  at  once  reach  Pfliiger,  to  whom 
we  owe  also  the  expression  of  the  phenomena  of  nerve-reactions 
to  different  current-strengths  in  their  simplest  formula  : — 


Ascending  Current. 

Descending  Current. 

Current. 

Make. 

Break. 

Make. 

Break. 

Weak 

Contraction 

Kest 

Contraction 

Rest 

Medium 

Contraction 

Contraction 

Contraction 

Contraction 

Strong 

Kest 

Contraction 

Contraction 

Kest  (or  weak  C.) 

1  Loc.  eit. 


*  '  Archiv  fur  physiologische  Heilkuude,'  1857. 


IN  PHYSIOLOGY  AND  THERAPEUTICS.  25 

Pfluger  did  not  remain  content  with  leaving  his  law  of  con- 
traction and  his  law  of  electrotonus  side  by  side ;  but  by  a 
further  induction  reduced  the  one  to  the  other,  and  showed  in 
the  happiest  manner  that  a  nerve  is  stimulated  by  the  appari- 
tion of  katelectrotonus,  and  the  disappearance  of  anelectro- 
tonus  ;  that  is,  by  the  passage  of  a  lesser  to  a  greater  degree 
of  irritability-  In  other  words,  that  the  stimulation  occurs  at 
one  electrode  only  :  at  the  kathode  on  closing,  at  the  anode 
on  opening  the  current.  He  completely  exposed  the  fallacy 
of  the  views  of  the  previous  writers,  who  had  all  explained  by 
the  differences  in  the  direction  of  the  current  itself  the  dif- 
ferent results  they  obtained  by  the  making  and  breaking  of 
ascending  and  descending  currents ;  and  showed  that  it  was 
the  relative  position  of  the  two  poles  to  one  another,  and  not 
to  the  direction  of  the  nerve-impulse,  that  was  the  condition 
upon  which  depended  the  variations  in  the  results  obtained. 

His  argument  was  based  on  the  facts  that  the  closure  of  the 
current  is  a  more  powerful  stimulant  than  the  opening ;  that 
anelectrotonus  takes  more  time  and  stronger  currents  to  de- 
velope  than  katelectrotonus ;  and  that  immediately  after  the 
opening  of  the  polarising  current  the  katelectrotonic  zone 
passes  into  a  condition  of  transitory  diminution  of  irritability, 
or  "  negative  modification,"  whilst  the  anelectrotonic  zone 
passes  immediately  into  one  of  increased  irritability,  or  "  posi- 
tive modification."  Thus  it  becomes  clear  why  weak  currents 
excite  the  nerve  at  the  closure  only :  anelectrotonus  is  not 
sufficiently  developed  by  them  to  cause  a  contraction  on  its 
disappearing,  nor  to  prevent  the  transmission  of  the  katelectro- 
tonic stimulus  from  above.  Strong  currents,  on  the  other  hand, 
develop  a  powerful  anelectrotonus,  and  negative  variation, 
which  arrest  the  make,  and  break  impulse  from  above  respec- 
tively. Medium  currents  allow  a  sufficient  anelectrotonus  to 
set  in  which  will  stimulate  on  disappearing ;  but  not  to  arrest 
the  central  katelectronic  impulse,  whilst  the  negative  modifica- 
tion of  the  katelectrotonic  region  also  is  too  weak  to  arrest  the 
stimulation  produced  by  the  disappearance  of  anelectrotonus 
on  the  breaking  of  the  descending  current. 

In  presence  of  the  clear  fact  that,  according  to  Pfliiger,  stimu- 
lation is  produced  at  the  kathode  on  closing,  at  the  anode  on 


26         CONDITIONS  OF  THE   UNIPOLAR   STIMULATION 

opening  of  the  current,  and  at  the  former  more  readily  than 
at  the  latter,  it  is  difficult  to  see  how  many  electrotherapeu- 
tical  writers  have  been  able  to  continue  speaking  of  the  results 
obtained  by  physiologists  as  dependent  on  the  direction  of  the 
current  with  reference  to  the  nerve;  and  to  place  their  so- 
called  "  polar  method  "  in  a  position  of  antagonism  to  the 
*  physiological  method." 1  In  the  latter,  it  is  true,  in  order  to 
eliminate  many  disturbing  elements,  such  as  the  influence  of 
the  central  organs,  the  action  of  derived  currents,  &c,  the  nerve 
is  usually  exsected,  and  both  poles  applied  to  it  directly  ;  but 
apart  from  these  differences  of  manipulation,  there  is  no  such 
fundamental  difference  between  the  two  methods  as  has  been 
claimed.  Let  us  first  throw  a  retrospective  glance  into  the 
origins  of  that  polar  method,  the  subject  of  so  many  mis- 
understandings and  passionate  recriminations. 

Among  the  earlier  observers  we  come  across  but  few  and 
vague  data  concerning  the  effects  of  the  galvanic  current  on 
the  living  body.  Bitter 2  noticed  that  a  strong  current  flowing 
from  hand  to  hand  produced  in  the  arm  up  which  it  flows  a 
sensation  of  increased  mobility,  and  vice  versa.  Matteucci3 
repeated  the  observation  of  Nobili,  that  tetanised  frogs'  legs 
were  quieted  by  an  ascending  current,  and  even  proposed 
therapeutical  applications  of  this  fact.4  Valentin5  is  the  first 
to  make  an  explicit  statement  on  the  subject.  He  finds 
that  in  the  living  animal  contraction  occurs  most  readily 
on  closing  the  current,  whatever  be  its  direction.  Fick  and 
Orelli6  found  the  same  happen  in  their  experiments  on  the 
ulnar  nerve  in  man.  Schiff7  puts  down  as  a  law  that  "con- 
traction occurs  in  the  living  subject  on  making  the  current  in 

1  Hermann  says  (loc.  cit.  vol.  ii.  p  63)  :  "  Pfliiger  the  first  showed  that  stimu- 
lation of  the  nerve  occurs  at  one  electrode  only,  on  making  the  current  at  the 
kathode,  on  breaking  it  at  the  anode";  and  recognises  Chauveau's  independent 
discovery  of  the  same  fact.  Biedermann,  by  the  way  ("  Uber  die  polaren  Wirkun- 
gen  des  elektrischen  Stromes  im  entnervten  MuskcJ,"  *  Sitzungsberichte  der  K.  K. 
Akad.  d.  Wissenschaften,'  vol.  lxxix.  p.  289),  has"  successfully  demonstrated  the 
polar  effects  on  curarised  muscle. 

2  '  Beitrage  z,ur  nahere  Kcnntniss  des  Galvanismus,'  Jena,  1S02. 

3  '  Essai  sur  les  Phenomencs  electriques  des  Animaux,'  1810. 

4  Cf.  '  Traite'  defl  Phcnomenos  eloclro-physiologiqucs,'  chap,  ix.,  "  Usage 
tlic'ripeutique  du  Cuiirant  continu."     1844.  °  Loc.  cit. 

6  '  Wiener  Mcdiciiii&cho  Wochcnschriit,'  1856. 

7  '  Lehrbuch  der  Nervenphysiologic,'  p.  80,  1856. 


IN   PHYSIOLOGY   AND   THERAPEUTICS.  27 

either  direction,  but  no  contraction  on  breaking  it,"  adding, 
it  is  true  that  in  his  experiments  he  never  closed  the  current 
for  more  than  five  seconds.  Claude  Bernard,  whose  classical 
lectures  appeared  at  the  same  time,1  says  that  "  a  nerve  placed 
in  normal  organic  conditions,  fit  to  transmit  voluntary  im- 
pulses, gives  only  one  contraction,  which  occurs  on  closing  the 
current,  whatever  be  its  direction,"  adding  that  deviations 
from  this  law  depended  on  the  mutilation  of  the  nerve.2  This 
point  has  been  lately  taken  up  by  Eumpf,3  chiefly  from  a 
clinical  point  of  view.  He  shows  that  the  apparition  of  the 
A.O.C.  is  delayed  by  the  influence  of  the  central  organs  and 
hastened  by  the  removal  of  this  influence.  There  is  thus 
a  qualitative  disturbance  of  the  normal  galvano-nervous 
formula,  which  has  escaped  notice  hitherto,  owing,  probably, 
to  the  shortness  of  the  period  at  which  it  is  recognisable — a 
few  days  only,  immediately  after  the  injury.  The  subject 
deserves  further  investigation,  but  much  care  is  required  to 
avoid  fallacies.  It  is  probably  owing  to  the  influence  of 
Remak4  that  electro-therapeutists  have  had  so  much  difficulty 
in  realising  the  full  bearings  of  Pfliiger's  conclusions.  Remak's 
researches  on  the  effects  of  the  galvanic  current  on  the  nerves 
in  the  living  subject  were  mainly  directed  to  the  phenomenon 
of  "  galvanotonus,"  that  is,  of  contraction  during  the  con- 
tinuous flow  of  the  current.  This  he  found  to  be  more  marked 
when  the  current  was  descending. 

Grapengiesser,  as  early  as  1801,5  had  expressed  himself 
clearly  to  the  effect  that  the  negative  pole  was  the  more 
effectual  of  the  two,  both  at  the  closing  and  during  the 
passage  of  the  current.  Remak  takes  extraordinary  pains  to 
show  that  this  superiority  of  the  kathode,  due  to  its  chemical 
properties,  exerts  no  influence  on  the  results  of  the  transverse 
stimulation   of  nerves.      If,  for  instance,  the  two  poles  are 

1  '  Lecons  sur  la  Physiologic  du  Systeme  nerveux,'  vol.  i.,  1858. 

2  Similar  observations  were  made  by  Pfliiger,  Bezold,  and  Rosenthal.  See 
Meissner's  '  Bericht '  for  1858.  Romanes  (Proc.  Roy.  Soc.,  1876  and  1877)  has 
measured  the  changes  in  the  excitability  of  the  frog  nerve  produced  by  injury. 
Thus,  before  section  A.C.  =  90;  K.C.  =  100;  A.O.  =  14;  K.O.  =  G;  whilst  after 
section  A.C.  =  140;  K.C.  =  300;  A.O.  =  105 ;  K.O.  =  14. 

3  '  Archiv  f.  Psychiatric,'  vol.  viii.  p.  507. 

*  '  Calvanothc'rapie,'  1850.  5  Quoted  by  Remak,  loc.  cit.,  p.  102. 


28         CONDITIONS   OF   THE   UNIPOLAR   STIMULATION 

placed  on  the  temples,  it  is  noticed  that  contractions  are  more 
readily  obtained  on  the  side  of  the  kathode;  but  this  is 
probably  due  to  the  fact  that  the  current  there  is  "ascending," 
for  the  current  avoids  the  resisting  bones,  and  passes  round 
about  the  forehead.  Even  were  this  not  the  case  the  pheno- 
menon could  be  readily  explained  by  the  assumption  that  a 
nerve  is  more  readily  stimulated  by  a  current  flowing  trans- 
versally  through  it  from  its  inner  to  its  outer  aspect  than  in 
the  opposite  direction  ! \ 

The  method  usually  spoken  of  in  electrotherapeutics  as 
"Brenner's  polar  method"  was,  so  far  as  its  physiological 
basis  is  concerned,  fully  described  by  Baierlacher  in  1859.2 
Before  entering  upon  this  subject,  I  may  be  allowed  to  offer  a 
few  remarks  on  the  impropriety  of  the  word  "  polar."  By  it  is 
implied  that  the  method  rests  upon  a  recognition  of  polar, 
instead  of  directional,  influences,  and  is  meant  to  distinguish  it 
from  the  so-called  "  physiological "  method.  But  the  truth  is, 
that,  as  we  have  already  stated,  in  physiology,  since  Pfluger, 
it  is  to  the  specific  action,  chemical  or  otherwise,  of  each  pole 
that  the  effects  of  the  current  are  attributed.  The  physio- 
logical is,  therefore,  a  polar  just  as  much  as  the  therapeutical 
method;  the  first  is  k'polar,  the  other  wm'polar.  By  these 
terms  we  simply  mean  that  either  both  poles  or  only  one  pole 
is  applied  to  the  nerve.  I  need  hardly  point  out  that  the 
term  unipolar,  taken  in  this  sense,  has  nothing  to  do  with  the 
unipolar  effects  of  induction  discovered  by  Du  Bois  Reymond 
in  1845,3  and  since  then  studied  by  a  large  number  of 
observers.4 

In  order  to  let  the  reader  judge  for  himself  how  far  Baier- 
lacher had  anticipated  Brenner,  I  quote  some  abstracts  : — 

"  The  unipolar  method  of  nerve-stimulation  adopted  by 
me  gives  us  the  opportunity  of  observing  the  separate  action 
of  each  pole  on  the  nerve,  whereby  we  attain  the  peculiar 
conclusion  that  the  same  phenomena  are  produced  which  we 
are  accustomed  to  consider  as  depending  upon  the  direction 

1  Sounder  views,  however,  prevail  in  Remak's  later  writings,  e.g.,  in  his 
•Lecons  sur  l'Application  du  Courant  continu.'     Paris,  18G5. 

2  '  Zeitschrift  fur  rationello  Medicin,'  series  III.,  vol.  v.,  p.  233.  Compare 
Meissner's  abstract  in  '  Bericht,'  ibid.,  vol.  vi.  p.  442. 

*  '  Untcrsuchuugon,'  vol.  i.  p.  423.  *  See  Hermann,  loc.  cit.,  p.  86. 


IN   PHYSIOLOGY  AND  THERAPEUTICS.  29 

of  the  current.  The  positive  pole  on  the  nerve  gives  us  the 
results  of  the  '  ascending,'  the  negative  of  the  '  descending,' 
current."  x 

The  nerve  chosen  by  Baierlacher  for  his  first  experiments 
was  the  peroneal,  near  the  head  of  the  fibula ;  and  the  result 
of  numerous  experiments  was  that,2  "  with  the  negative  pole 
on  the  nerve,  the  closure  contraction  was  very  strong,  the 
opening  contraction  absent,  or  exceedingly  feeble.  With  the 
positive  pole  to  the  nerve,  the  opposite  took  place,  the  closure 
contraction  being  absent  or  very  weak,  the  opening  contraction 
strong."  Thus  the  order  was  K.C.C.,  A.O.C.,  A.C.C.,  K.O.C. : 
a  more  accurate  statement  than  that  of  Brenner,  who  places 
A.C.C.  before  A.O.C.,  owing  probably,  as  we  shall  see,  to  a 
want  of  care  in  applying  his  electrode.3 

The  author  further  states  4  that  "  there  can  be  no  question 
about  a  difference  in  the  direction  of  the  currents"  in  his 
experiments,  as  the  contractions  appeared  in  the  same  order 
whether  the  indifferent  electrode  was  placed  above  or  below 
the  other.  He  displays  considerable  acumen  in  the  remark 
that,  even  with  these  changes  in  the  position  of  the  indifferent 
electrode,  the  upward  or  downward  direction  of  the  current  can 
be  but  of  secondary  influence,  compared  with  that  exerted 
by  the  very  different  densities  of  the  current  at  its  points  of 
entrance  into,  and  exit  from,  the  nerve  respectively. 

Baierlacher  also  repeated  the  experiment  of  Tick  with  both 
poles  on  the  ulnar  nerve,  and  came  to  the  conclusion  that  the 
order  of  contractions  was — 


Current. 

Descending. 

Ascending. 

Closure. 

Very  Strong. 

Strong 

Opening 

Absent  or  Weak 

Moderate 

A  result  which  coincides  with  the  view  that  the  anodal 
reactions  of  the  unipolar  method  correspond  with  the  "as- 
cending," the  kathodal  reactions  with  the  "  descending,"  reac- 

1  Page  253.  *  Page  249. 

s  Or,  at  least,  to  Lis  using  a  too  large  'different '  electrode.  4  Page  251. 


30         CONDITIONS  OF  THE  UNIPOLAK   STIMULATION 

tions  of  the  bipolar  method.  This  point  is  recognised  by 
Meissner.1 

Chauveau,  at  the  same  time,  following  an  entirely  different 
train  of  thought,  came  to  similar  conclusions :  a  result  all  the 
more  meritorious  that  he  worked  in  complete  ignorance  of  all 
that  was  being  done  in  Germany,  and  laboured  under  serious 
misconceptions,  such  as  an  imaginary  influence  of  electrical 
"  tension  "  and  of  "  extra-currents."  His  experiments 2  were 
made  with  Leyden  jars,  induction  coils,  and  galvanic  batteries. 
The  two  former  bring  about  contractions  more  readily  at 
the  negative  than  at  the  positive  pole.  On  making  a  weak 
galvanic  current,  stimulation  occurs  at  the  negative  pole  only ; 
the  direction  of  the  current  has  no  influence  whatever.  For 
instance,  when  the  poles  are  on  the  sciatic  plexus  and  the 
lower  part  of  the  sciatic  nerve,  contractions  occur  in  the  thigh 
and  leg  when  the  cathode  is  on  the  plexus ;  in  the  leg  only, 
when  it  is  on  the  nerve. 

The  opening  contraction  occurs,  under  similar  conditions, 
at  the  positive  pole.  In  every  case  the  indifferent  pole  may 
be  applied  to  any  part  of  the  body  without  changing  the 
results.  Space  does  not  allow  me  to  indicate  more  than 
the  general  results  of  Chauveau's  elaborate  papers.3  A  good 
abstract  of  his  researches  has  been  given  by  Meissner,  who 
adds4  that  these  results  coincide  with  those  of  Baierlacher, 

1  Loc.  cit. 

2  "  Theorie  des  effets  physiologiques  produits  par  l'electricite  transmise  dans 
l'organisme  animal  a  l'etat  de  courant  instantane  ou  de  courant  continu,"  'Journal 
de  la  Physiologie,'  1859,  pp.  490,  553,  1860,  pp.  52,  274,  458,  534,  ff.  See  also 
Meissner's  '  Bericht,'  in  '  Zeitschrift  fur  rationelle  Medicin,'  1860,  p.  554. 

3  I  cannot  here  pass  under  silence  Chauveau's  latest  contributions  to  the 
subject  of  unipolar  stimulation.  ('  Comptes  Rendus  de  l'Acade'mie  des  Sciences,' 
1875,  1876,  vols,  lxxxi.  pp.  779,  824,  1038,  1193,  and  lxxxii.  p.  83).  In  a 
series  of  notes  to  the  Academy  he  has  formulated  a  number  of  propositions  which 
are  mostly  in  direct  contradiction  to  all  the  received  views,  and  his  own  former 
results.  His  recent  experiments  have  been  made  both  on  frogs'  and  mammalians' 
nerves.  To  discuss  them  here  is  impossible,  as  they  are  but  briefly  described ; 
but  they  will  have  to  be  carefully  controlled.  He  reaches  the  astonishing  con- 
clusion, that  for  every  motor-nerve  there  exists  a  current-strength  (usually  very 
weak)  which  gives  to  both  poles  the  same  degree  of  activity.  Below  it  is  the 
negative  pole,  above  the  positive,  which  preponderates.  For  sensory  nerves  it  is 
the  opposite  that  holds. — What  precedes  applies  to  the  closure  of  the  current.  On 
opening  also,  Chauveau  finds  the  positive  pole  the  more  active.  His  results  are 
embodied  in  a  number  of  tracings  and  tables  of  curves. 

4  Loc.  cit.,  p.  455. 


IN   PHYSIOLOGY  AND   THERAPEUTICS.  31 

and  with  Pfliiger's  theory  that  stimulation  is  produced  at  the 
appearance  of  katelectrotonus  ( =  closure  contraction  when  the 
kathode  is  on  the  nerve),  and  at  the  disappearance  of  analectro- 
tonus  (  =  opening  contraction  when  the  anode  is  on  the  nerve).1 
The  untiring  zeal  and  brilliant  success  of  Brenner  in  apply- 
ing the  unipolar  method  to  the  practice  of  electro-diagnosis, 
his  success  in  upsetting  the  obsolete  views  of  Remak  and 
his  followers,2  are  quite  sufficient  to  secure  him  a  promi- 
nent place  in  the  history  of  the  question ;  though  Pfliiger's 
law,  rightly  understood,  on  one  side,  and  the  results  of 
Baierlacher  and  Chauveau  on  the  other,  deprive  him  of  the 
priority  which  seems  generally  to  be  conceded  to  him.  It 
was  only  in  1862  3  that  he  first  published  his  "  discovery  "  that 
the  closure  contraction  depended  upon  the  negative  pole,  the 
opening  contraction  upon  the  positive.  In  his  great  work4 
he  has  collected  a  vast  array  of  experiments  and  illustrations 
in  support  of  his  views.  The  first  volume  is  devoted  to  the 
application  of  the  unipolar  method  to  the  acoustic  nerve, 
which  gives  a  very  pure  series  of  reactions  in  the  normal 
condition,  responding  to  the  cathodal  closure  (and  duration) 
and  anodal  opening  only.  He  endeavours  to  base  a  rational 
system  of  electro-otiatrics  on  this  result.  In  the  second 
volume  he  describes  the  apparatus  and  manipulations  neces- 

1  I  think  I  may  fairly  claim  as  supporting  the  main  argument  of  this  paper  the 
results  obtained  by  Morat  and  Toussaint  ('  Comptes  Rend  us  de  1' Academic  des 
Sciences,'  1877,  vol.  lxxiv.,  p.  503),  with  reference  to  the  electrotonic  state  of 
nerves  excited  on  the  unipolar  method.  These  observers  found  that  the  modifi- 
cations were  of  the  same  order  on  both  sides  of  the  point  of  application  of  the 
electrode.  "When  the  kathode  was  applied,  the  modification  was  positive  at  both 
ends  ;  when  the  anode,  the  modification  was  negative.  Now,  in  the  usual 
bipolar  application,  the  modification  at  each  end  is  of  the  same  name  ns  the 
neighbouring  pole.  The  authors  explain  the  results  of  the  unipolar  excitation 
by  saying  that  the  current  follows  the  nerve  in  two  directions ;  opposed  to  the 
natural  nerve  current  in  one  case,  concordant  with  it  in  the  other ;  hence  the 
negative  and  positive  modifications.  But  is  it  not  simpler  to  assume  that  it  is  the 
virtual  anodes  or  kathodes,  on  either  side  of  the  actual  electrode,  which  produce 
the  phenomenon?  When  the  positive  pole  is  on  the  nerve,  the  two  virtual  kathodes 
will  naturally  call  forth  the  negative  modification  at  each  end ;  and  the  opposite 
will  happen  when  it  is  the  negative  pole  whicli  is  in  contact  with  the  nerve. 

2  See,  for  instance,  Benedikt,  '  Elektrotlierapie,'  1st  Edition,  1866,  so  unspar- 
ingly criticised  by  Brenner  in  his  '  Untersuchungen,'  vol.  ii.  p.  208,  ff. 

3  '  St.  Petersburger  Medicinische  Zeitschrift,'  vol.  iii. 

4  'Untersuchungen  und  Beobachtungen  auf  dem  Gebiete  der  Elektrotherapie,' 
Leipzig,  1868-69. 


32         CONDITIONS  OF  THE  UNIPOLAR  STIMULATION 

sary  to  operate  successfully,  discusses  the  relations  of  the 
"  polar "  to  the  "  physiological "  methods,  and  makes  a  sub- 
stantial contribution  to  the  art  of  electro-diagnosis. 

The  effect  of  Brenner's  work  was  to  call  forth  a  controversy 
as  violent  as  it  was  useless,  but  it  stimulated  also  the  zeal  of  a 
large  number  of  workers  in  the  field.  Though  the  din  and 
dust  of  the  battle  caused  the  loss  of  much  time  and  temper, 
there  gradually  arose  clearer  views,  and  valuable  results  were 
obtained.  The  question  of  the  possibility  of  demonstrating 
the  phenomena  of  electrotonus  in  the  living  human  nerve 
occupied  the  attention  of  several  observers.  First,  Fick,1 
whose  results  were  negative,  then  Eulenburg2  and  Erb3 
appear  in  the  field.  Eulenburg,  applying  the  galvanic  current 
to  an  accessible  nerve,  such  as  the  peronseus,  ulnar,  &c,  tested 
its  irritability  by  means  of  an  induced  current  below  the  point 
of  application.  His  results  were  in  accordance,  apparently, 
with  those  obtained  on  the  exsected  frog's  nerve;  and  he 
found  increased  or  diminished  irritability  when  he  produced 
descending  extrapolar  katelectrotonus  or  anelectrotonus.  Erb 
was  not  so  successful  in  his  first  experiments,  and  found  a 
complete  inversion  of  the  phenomena,  though  he  followed  a 
method  similar  to  Eulenburg's.  Helmholtz  4  thereupon  made 
an  important  suggestion,  which  seems  to  me  to  contain,  as  in 
a  germ,  the  solution  of  the  main  difficulties  encountered  in 
the  experimentation  on  the  living  body,  and  which  will  be 
developed  further  on.  He  said  that  Erb's  paradoxical  results 
might  be  due  to  the  fact  of  the  electrical  diffusion,  which 
in  the  immediate  neighbourhood  of  the  electrode  must  be 
sufficiently  considerable  to  justify  the  assumption  that  it  there 
acts  as  an  opposite  pole.  Acting  upon  this  supposition,  Erb 
tested  the  condition  of  the  nerve  immediately  under  the 
electrode,  and  found  it  coincide  with  that  obtaining  in  physio- 
logical experiments.      The  results  of  Samt5  are  interesting 

1  •  Medicinische  Physik,'  1866. 

2  "  Ueber  elektronisirende  Wirkung  bei  pereutoner  Anwendung  des  constanten 
Stromes  auf  Nerven  und  Muskel,"  'Deutsches  Archiv  fur  klinische  Medicin,' 
vol.  iii.  p.  117  (1867). 

3  '  Ueber  elektrotonische  Erscbeinungen  am  lebenden  Menscben,'  ibid.  p.  513  ; 
and  *  Galvanotberapeutische  Mittheilungen,'  ibid.,  pp.  238  and  333. 

4  In  an  oral  communication  to  tbe  Naturbistorisch-Medicinisch  Verein  meeting 
at  Heidelberg,  1867.  *  '  Der  Elektrotonua  am  Menechen,'  Berlin,  1868. 


IN   PHYSIOLOGY   AND   THERAPEUTICS.  33 

chiefly  on  account  of  his  conclusion  that  many  of  the  incon- 
sistencies among  the  results  obtained  on  the  human  subject 
are  clue  to  morbid  conditions  of  the  nerves  :  a  view  supported 
by  the  fact  that  the  gradual  exhaustion  of  a  frog's  nerve  is  a 
frequent  cause  of  fallacy  in  experiments,  and  that  the  ventral 
organs  exert  a  marked  influence  in  the  time  of  apparition  of 
the  several  reactions. 

Bruckner's  results *  do  not  throw  much  further  light  upon 
the  subject;  but  the  method  he  used  suggested  to  Runge2 
a  series  of  experiments  which  are  described  in  a  very  able 
paper.  This  method  consisted  in  intercalating  in  the  circuit 
of  the  polarising  current  the  secondary  coil  of  the  testing 
instrument.  Bruckner  found  that  when  the  two  currents 
moved  in  opposite  directions  the  effect  was  diminished  at  the 
negative  pole  of  the  induced  current  especially.  Kunge  per- 
formed a  series  of  ingenious  experiments,  the  result  of  which 
goes  far  to  prove  that  in  all  anterior  electrotonic  experiments 
the  summation  of  effects  of  the  two  currents  must  be  the  real 
cause  of  the  phenomena,  and  not  the  altered  irritability  of  the 
nerve.  Ziemssen 3  coincides  with  this  view,  which  he  supports 
by  experiments  of  his  own.  But  he  justly  condemns  the 
sweeping  assertions  of  Runge,  who,  forgetting  the  results 
obtained  in  physiological  experiments  by  irritating  the  nerve 
with  chemical  agents,  would  explain  the  whole  question  of 
electrotonus  by  a  mere  antagonism  or  combination  between 
the  polarising  and  testing  currents. 

The  only  experiments  on  electrotonus  in  the  living  man 
where  due  care  was  taken  to  avoid  the  innumerable  sources  of 
fallacies  which  beset  all  such  attempts,  are  those  of  Cyon,4 
made  in  1868.  By  dint  of  trouble  and  care,  he  obtained 
normal  results  in  a  few  cases  :  a  significant  fact,  and  which, 
in  itself,  speaks  volumes  against  the  basing  a  therapeutical 
system  upon  the  supposed  electrotonic  influences  of  the  rough 

1  "  Ueber  die  Polarisation  des  lebenden  Nerven  in  Menschen,"  '  Deutsche 
Klinik,'  1868  and  1871. 

2  "  Der  Elektrotonus  am  lebenden  Menschen,"  '  Deutsche  Archiv  fur  klinische 
Medicin  '  (1870),  p.  356. 

3  '  Die  Electricit'at  in  der  Medicin,'  4th  Edit.,  pp.  63  ff. 

4  '  Principes  d'Electrothe'rapie,'  Paris,  1873.  At  the  same  time  I  fully  agree 
with  all  that  Erb  says  of  this  work  in  his  severe  review  of  it.  (Virchow's  '  Jah- 
resbericht '  for  1873.) 

VOL.    III.  D 


34  CONDITIONS   OF   THE   UNIPOLAR   STIMULATION 

and  ready  proceedings  usual  in  medical  applications  of  elec- 
tricity. Cyon  experimented  on  the  ulnar  nerve ;  he  found  it 
necessary  to  fix  the  arm  in  a  plaster  of  Paris  mould ;  applied 
the  polarising  electrodes  over  points  where  the  nerve  was 
superficial,  and  tested  the  extrapolar  descending  electrotonus 
by  means  of  induction  shocks.  The  electrotonic  condition 
was  expressed  in  terms  of  the  contractions  of  the  adductor 
pollicis ;  their  amplitude  being  registered  on  a  revolving  drum 
by  means  of  a  lever  attached  to  the  thumb.  The  cases  in 
which  he  was  unsuccessful  he  explains  partly  by  morbid 
conditions  of  the  nerve,  partly  by  the  influence  of  the  central 
organs ;  but  apparently  ignores  Helmholtz's  explanation, 
which  is  of  far  greater  importance,  that  the  disturbing 
element  lies  in  the  irregular  diffusion  of  the  current  from  the 
nerve  among  the  surrounding  tissues. 

Hitzig 1  in  a  valuable  contribution,  unfortunately  unfinished, 
among  other  points  discusses  the  reactions  of  the  acoustic 
nerve  to  the  galvanic  current.  It  is  the  only  nerve  of  the 
body  on  which  we  obtain  reaction  to  anodal  opening  and 
cathodal  closure  only.  The  reason  given  for  this  fact  by 
Hitzig  is  not  only  satisfactory,  but  most  suggestive.  The 
deviations  from  the  typical  formula,  he  says,  occurring  in  uni- 
polar excitation  of  other  nerves,  is  due  to  their  being  sur- 
rounded by  good  conductors,  as  suggested  by  Helmholtz,  with 
reference  to  Erb's  experiments  on  electrotonus.  Now  the 
acoustic  nerve  is  surrounded  by  bone,  a  bad  conductor,  and 
ends  in  a  substance  homogeneous  to  itself;  therefore  the 
whole  of  it  may  be  thrown  into  a  state  of  anelectrotonus  or 
katelectrotonus :  hence  the  purity  of  its  reactions.  I  fully 
agree  with  Hitzig  in  his  various  strictures  on  Brenner's  views  ; 
but  think  with  Erb2  that  it  is  a  fallacy  to  argue  to  the  abso- 
lute non-existence  of  polar  effects  from  the  inefhcacy  of  trans- 
verse electrisation  of  the  nerve.  May  it  not  be  assumed  that 
under  such  conditions  the  two  opposite  polar  actions  are  in 
equilibrium  and  neutralise  one  another  ? 3 

1  "  Ueber  den  relativen  Werth  einiger  Elektrisations  Methoden,"  '  Archiv  fur 
Psychiatrie,'  vol.  iv.  p.  159  (1874). 

2  "  Ueber  die  Auwendung  der  Elektricitiit  in  der  inncren  Medicin,"  '  Volk- 
niann's  Vortr'age,'  No.  46. 

3  The  possibility  of  transverse  stimulation  of  uervts  is  at  present  the  subject 


IN   PHYSIOLOGY  AND   THERAPEUTICS.  35 

Filchnc1  has  laboured  very  hard  to  reconcile  the  "thera- 
peutical "  and  "  physiological "  methods.  Considered  from  a 
general  point  of  view,  such  a  reconciliation  appears  unneces- 
sary :  impossible  indeed  from  a  more  special  standpoint,  since 
the  very  essence  of  the  bipolar  method  consists  in  acting  on  the 
isolated  nerve  with  the  two  poles  at  their  full  undivided  power ; 
whilst  that  of  the  unipolar  method  consists  in  eliminating,  as 
much  as  possible,  by  scattering  it,  the  effect  of  one  of  the  poles. 
Pfliiger  having  shown  that  contraction  depends  on  purely  polar 
effects,  the  problem  was  rather  to  explain  how  it  is  that  with 
the  unipolar  method  the  anodal  closure  usually  preceded  the 
anodal  opening  contraction,  and  how  anodal  closure  and  catho- 
dal opening  contractions  occurred  at  all.  Filehne  has  done 
this  but  very  imperfectly.  He  shows  that  in  unipolar  excita- 
tion the  current  diffuses  both  up  and  down  the  nerve;  and 
that  the  results  were  as  if  half  the  neutral  pole  was  placed 
above,  and  half  below  the  active  pole.  We  readily  grant 
this,  but  then  are  at  a  loss  to  understand  how  he  ever  could 
obtain  results  comparable  to  those  of  the  bipolar  method,  as 
he  never  opposed  but  the  inferior  half  of  the  divided  to  the 
whole  undivided  pole.  In  fact,  his  experiments  repeated  by 
Burkhardt 2  led  this  observer  to  different  results.  As  to  his 
experiments  with  excessive  currents — 8-30  cells  to  a  frog's 
nerve,  50  cells  to  a  rabbit's ! — in  which  he  obtained  anodal 
make  and  kathodal  break  contractions  only,  we  may  safely 
assume  that  this  phenomenon  was  rather  due  to  injury  to  the 
nerve  from  the  powerful  chemical  action,  and  hardly  adducible 
as  corresponding  to  Pfliiger's  third  stage.  At  any  rate  Burk- 
hardt did  not  find  it  at  all  constant  in  its  occurrence.  It 
must  be  noted,  by  the  way,  that  Filehne  does  not  mention  how 
far  he  confirmed  his  data— apparently  obtained  from  very  few 
experiments — by  an  extended  series  of  controlling  tests,  a  very 
necessary  precaution  in  this  field  of  inquiry.  It  has  also  to 
be  proved  that  the  greater  irritability  of  the  upper  part  of  the 

of  a  controversy  between  Tschiriew,  who  has  affirmed  it  (*  Archiv  f.  Physiologie,' 
1877  and  1879),  and  Hermann,  who  denies  it  ('  Handbuch,'  1879,  vol.  ii.  p.  80). 

1  "  Die  electrotherapeutische  und  die  physiologische  Reizmethodc,"  '  Deutsches 
Archiv  flir  klinische  Medicin,'  vol.  vii.,  p.  575,  1870. 

2  '  Physiologische  Diagnostik  der  Nerveu  Krankheiten,'  1875. 

D   2 


36         CONDITIONS  OF  THE  UNIPOLAR  STIMULATION 

exsected  frog's  nerve  is  not  the  result  of  mutilation,  before 
assuming,  as  he  and  others  have  done,  that  the  anodal  stimula- 
tion corresponds  to  the  descending,  and  cathodal  to  the  ascend- 
ing current.  Baierlacher  and  Meissner,  as  stated  above,  held 
an  opposite  view.1  Filehne's  views  of  a  "  peripolar  "  stimula- 
tion, it  may  be  added,  remind  one  very  much  of  the  experi- 
ments of  Eousseau,  Lesure,  and  Martin  Magron,2  in  illustration 
of  the  fallacies  in  the  results  of  Longet  and  Matteucci,  due  to 
the  existence  of  derived  currents  in  the  undivided  nerve. 
Chauveau3  had  also  shown  that  the  effects  of  lifting  out 
the  nerve  on  the  electrode,  and  so  exciting  it  by  a  true 
"  peripolar  "  current,  whilst  the  other  was  applied  to  the  limb, 
were  the  same  as  those  of  unipolar  excitation  of  the  nerve 
in  situ. 

In  much  of  what  has  been  written  on  the  subject  of  unipolar 
stimulation,  there  seems  to  me  to  underlie  a  fundamental  fal- 
lacy :  I  mean  a  confusion  between  positive  and  negative  poten- 
tial, and  positive  and  negative  pole  (or  anode  and  kathode). 
It  is  quietly  assumed  that  when,  for  instance,  an  electrode  is 
held  in  each  hand,  one  of  the  arms  is  under  an  anodal,  the 
other  under  cathodal  influence ;  but  the  fact  is,  they  are 
simply  at  potentials  different,  positively  and  negatively,  from 
that  of  the  earth.4  It  cannot  too  strongly  be  dwelt  upon  that 
potential  means  simply  level,  and  differences  of  electrical  poten- 
tial differences  of  electrical  level,  without  which  a  flow  of 
electricity  is  impossible.  But  by  anode  and  kathode  we  mean 
a  totally  different  thing ;  we  mean  the  point  of  entrance  of 
the  current  into,  and  its  point  of  exit  from,  an  electrolyte,  that 
is,  a  conductor  in  which  electrolysis  is  set  up.  Further,  in  a 
circuit  composed  of  several  electrolytes,  the  boundary  between 
each  pair  of  electrolytes  acts  as  kathode  to  the  one  which  the 
current  leaves,  and  as  anode  to  the  one  which  it  enters. 

It  is  clear  then  that  in  sending  a  current  through  a  compo- 
site electrolyte,  such  as  the  human  body,  there  can  be  no 
question  of  exclusive  localisation  of  "  polar  "  effects.    At  every 

1  See  Heidenhnin,  •  Meissner 's  Bericht,'  1857,  p.  420. 

2  'Gazette  Medicule,'  1858;  see  also  Bernard's  'Logons  sur  la  Physiologie  du 
Systeme  nerveux,'  vol.  i.  p.  180. 

*  Loc.  cit.  4  De  Watteville,  'Introduction  to  Medical  Electricity,'  p.  111. 


IN  PHYSIOLOGY   AND  THERAPEUTICS.  37 

point  where  the  current  passes  from  one  liquid,  one  tissue,  or 
one  cell,  into  another,  there  is  an  anode  and  a  kathode,  each 
endowed  with  its  full  chemical  and  physiological  properties. 
Let  us  consider  what  takes  place  when  the  positive  electrode 
is  applied  to  the  skin  over  a  nerve.  The  current  passes 
through  the  epidermis  and  subjacent  layers,  and  part  of  it 
enters  the  nerve-fibres ;  at  this  point  we  have  what  I  call  the 
virtual  anode.  The  greater  portion  of  the  electricity  which 
has  entered  the  nerve  leaves  it  almost  immediately,  on  account 
of  the  better  conductivity  of  the  surrounding  tissues :  these 
points  of  emergence  form  the  virtual  kathode  of  the  nerve. 
The  relative  density  of  the  current  at  the  virtual  electrodes 
depends  upon  its  diffusion ;  and  this  again  is  regulated 
entirely  by  physical  conditions,  viz.  the  relative  position  of 
the  actual  electrodes,  and  the  relative  conductivity  of  the 
nerve  and  surrounding  tissues.1 

Now,  it  is  upon  the  action  of  the  virtual  electrodes  that  the 
phenomena  of  electrotonus,  and  hence  of  contraction,  depend ; 
and  this  consideration  is,  in  my  opinion,  capable  of  explaining 
all  the  apparent  anomalies,  without  any  reference  to  a  "  peri- 
polar "  direction  of  current,  or  any  such  hypothesis.  The 
appearance  of  katelectrotonus  is  a  more  powerful  stimulant 
than  the  disparition  of  anelectrotonus.  Hence  when  the 
positive  pole  is  over  the  nerve,  though  the  virtual  anode  is 
denser2  than  the  virtual  kathode,  the  latter  will  overtake  the 
former,  and  produce  a  closer  contraction,  equal  to  or  stronger 

than  the   opening  contraction,  as  soon  as  yr^-  is  equal  to  or 

greater  than  g^-  (when  D.  and  S.  stand  for  density  and  stimu- 
lating energy  of  anode  and  kathode  respectively).  Hence  also 
the  great  preponderance  of  kathodal  closure  over  kathodal 
opening  :  the  latter  labours  under  double  disadvantage,  since 
the  virtual  anode  now,  besides  its  inherent  inferiority,  is  not 
sufficiently   dense    to    exert   much    influence.      Brenner,  in 

1  If  a  nerve  lie  isolated  at  any  point  of  its  course,  and  placed  in  contact  with 
an  electrode  whilst  the  circuit  is  closed  at  any  pai  t  of  the  body,  the  virtual  elec- 
trodes of  the  opposite  name  will  be  at  the  points  where  the  nerve  emerges  from 
the  surrounding  tissues. 

2  And  hence  more  effective :  Du  Bois  Reymon.l's  law. 


33  CONDITIONS   OF   THE   UNIPOLAK   STIMULATION 

presence  of  the  kathodal  opening  and  anodal  closure  con- 
tractions, tried  to  explain  them  away  by  a  mutual  "over- 
taking "  (iibergreifen)  of  both  poles. 

In  proportion  as  we,  by  the  position  of  the  actual  electrode, 
can  increase  the  difference  of  density  between  the  two  virtual 
electrodes  we  obtain  purer  polar  effects.  It  is  in  this  sense 
that  Hitzig's  explanation  of  the  acoustic  reactions  must  be 
taken.  With  most  nerves  of  the  body  it  is  impossible  even  to 
approximate  the  normal  formula ;  but  in  a  few  cases  (such  as 
with  the  ulnar  at  the  elbow  and  wrist,  and  the  peroneal  at  the 
head  of  the  fibula)  we  obtain  results  which  go  far  to  prove  my 
theory.  If,  for  instance,  one  pole,  being  as  usual  on  a  distant, 
"  indifferent "  part  of  the  body  (the  back,  the  sternum,  &c), 
the  "  differential  "  electrode  is  applied  over  the  ulnar,  close  to 
the  wrist,  we  obtain  a  series  of  contractions,  K.C.C.,  A.O.O., 
A.C.C.  (K.O.C.).  Here  we  remark  that  A.O.C.  >  A.C.C.  as  it 
should  be  ;  but  if  we  push  the  electrode  a  little  higher  up, 
where  the  nerve  is  immediately  surrounded  by  good  con- 
ductors (muscle  and  blood-vessels),  we  find  A.O.C.  =  A.C.C, 
and  finally  A.O.C.  <  A.C.C.  The  explanation  of  this  fact, 
according  to  me,  is  simply  that  in  the  first  case  the  virtual 
kathode  is  spread  over  a  greater  length  of  the  nerve,  hence  not 
so  dense  and  effective ;  in  the  second,  the  current  leaving  the 
nerve  immediately  after  it  has  entered  it,  the  virtual  kathode 
is,  though  not  so  dense  as  the  virtual  anode,  still  sufficiently  so 
to  make  up  the  difference  by  its  physiological  preponderance. 

Brenner  gives  synoptical  tables  intended  to  prove  the  paral- 
lelism between  the  "  physiological  "  and  his  "  polar  "  method  ; 
but  with  the  exception  that  he  shows  that  "apparition  of 
katelectrotonus  "  is  synonymous  with  "  kathodal  closure,"  and 
"  disparition  of  anelectrotonus  "  with  "  anodal  opening,"  these 
tables  are  useless.  It  would  be  better  to  tabulate  the  different 
conditions  obtaining  in  the  two  methods.     For  instance : — 

Fhysiological  or  Bipolar.  Therapeutical  or  Unipolar. 

The  nerve  is  mutilated  and  exposed,  The  nerve  is  entire  and  lies  in  its 

in  direct  contact  with  the  electrodes,  physiological  and  anatomical  relations, 

It  is  separated   from   its  centres,  and  and  is  separated  from  the  actual  elec- 

fiom  its  blood-supply.  trodc  by  the  skin  and  other  tissues. 

The  actual  and  virtual  electrodes  are  The  current  at  the  virtual  electrodes 

one,  and  the  current  at  each  usually  of  is  of  different  and  unknown  densities ; 


IN    PHYSIOLOGY   AND   THERAPEUTICS.  39 

c<]unl  and  known  density.      They  are  the  whole  of  one  virtual  electrode  may 

placed  one  above  the  other.  roughly  be  said  to  be  between  the  two 

The  full  electrotonic  effects,  both  stimu-  halves  of  the  other, 

luting  and  inhibitory,  are  produced  at  The  electrotonic  effects  are  propor- 

each  electrode,  and  the  law  of  contractions  tional  to  these  densities,  and  the  order 

is  based  upon  (1)  the  greater  stimulating  and  time  of  contractions  depends  upon 

power  of  appearing  katelectrotonus,  (2)  (1)  the  greater  stimulating   power  of 

the  interference  of  appearing  anelectro-  katelectrotonus,  (2)  the  relative  density 

tonus  and  of  the  negative  variation  of  at  the  virtual  electrodes, 
disappearing  katelectrotonus. 

In  both  instances  the  condition  of  vitality  of  the  nerve  will 
of  course  have  to  be  considered  as  influencing  the  results.  In 
experiments  on  the  prepared  frog's  nerve  it  has  long  been 
noted  that  numerous  circumstances,  some  connected  with  the 
process  of  exsection,  others  independent  from  it,  exerted  a 
disturbing  influence  on  the  results.  In  many  cases  these 
circumstances  may  be  explained  on  the  grounds  that  where- 
ever  the  homogeneity  of  the  nerve-fibres  is  destroyed  a 
secondary  anode  and  kathode  exists.  Even  points  where  a 
considerable  nerve-branch  is  given  off  by  a  nerve  may  set  up 
such  secondary  electrodes,  owing  to  the  sudden  change  in  the 
diameter  of  the  nerve,  and  perhaps  in  the  relative  distribution 
of  the  connective  tissue,  which,  of  course,  is  to  be  looked  upon 
as  a  different  electrolyte  from  the  nerve-fibres.1  Again,  in 
arguing  from  unipolar  experiments  on  frogs,  a  possible  source 
of  fallacy  may  be  found  in  the  difference  between  the  relative 
conductivity  of  nerve  and  muscle  (and  other  tissues)  in  that 
animal  and  that  obtaining  in  man :  a  condition  which  would 
materially  alter  the  relative  densities  of  the  virtual  anodes, 
under  apparently  similar  circumstances.  Any  attempt  then, 
I  repeat,  at  reconciliation  between  the  unipolar  method  of  the 
electro-therapeutist  and  the  bipolar  method  of  the  physiologist 
is,  strictly  speaking,  meaningless,  for  there  is  nothing  to 
reconcile ;  they  start  from  the  same  fundamental  axiom.  The 
moment  the  different  conditions  under  which  they  act  in  each 
case  are  explained  the  whole  question  is  as  clear  as  we  can 
wish.  In  the  bipolar  method  there  is  an  element  which  does 
not  exist  in  the  unipolar :  that  of  the  inhibitory 2  effect  of  the 
lower  pole  on  the  influence  of  the  upper  pole.     This  effect 

1  Hering  ('  Sitzungsberichte  d.  K.  K.  Akad.  d.  Wissenschaften,'  Ixxix.)  makes 
similar  observations  with  reference  to  muscle.  2  '  Sit  vcnia  verbo  !' 


40         CONDITIONS  OF  THE   UNIPOLAR   STIMULATION 

comes  into  play  only  in  the  third  stage  of  Pniiger's  law,  where 
the  incipient  anelectrotonus  arrests  the  katelectrotonic  im- 
pulse at  the  closure  of  the  ascending  current,  and  the  negative 
modification  arrests  the  anelectrotonic  stimulation  at  the 
opening  of  the  descending  current.  Trying  to  find  anything 
similar  when  the  unipolar  method  is  used  is  a  contradiction 
in  terms,  a  begging  of  the  whole  question,  and  we  have  seen 
that  Filehne's  experiments  on  the  subject  are  open  to  grave 
suspicion. 

With  reference  to  the  experiments  on  the  production  of 
electrotonus  in  the  human  subject,  it  may  be  fairly  said  that 
they  have  led  to  very  scanty  results,  and  are  exposed  to  a  funda- 
mental objection :  that  of  the  summation  of  the  effects  of  the 
polarising  and  testing  currents.  But  do  we  need  any  such 
experiments  in  order  to  estimate  the  electrotonic  condition  of 
any  nerve?  Is  not  the  occurrence  of  opening  and  closure 
contractions,  the  best  proof  of  the  existence  of  anelectrotonus 
and  of  katelectrotonus  ?  Taking  the  occurrence,  then,  of  these 
contractions  as  an  index  to  the  condition  to  the  polarised 
nerve,  the  obvious  conclusion  is  that  it  is  very  rarely  indeed, 
and  on  a  very  small  scale,  that  we  can  ever  produce  any- 
thing like  a  pure  anelectrotonus.  In  almost  every  position  of 
the  actual  positive  electrode,  we  obtain  A.C.C  >  A.O.C. :  a 
proof  that  the  virtual  kathode  overpowers  the  virtual  anode, 
that  the  katelectrotonus  predominates  over  the  anelectrotonus. 
The  practical  conclusion  from  this  fact  is  that  a  therapeutical 
system  built  on  the  opposite  anelectrotonic  and  katelectrotonic 
effects  rest  upon  an  imaginary  basis.  In  by  far  the  great 
majority  of  cases  we  can  produce  only  predominant  katelectro- 
tonus ;  that  is  katelectrotonus  with  a  more  or  less  considerable 
admixture  of  anelectrotonus  in  its  immediate  neighbourhood. 
When  to  this  consideration  we  add  the  fact  that  anelectro- 
tonus immediately  passes,  on  breaking  the  current,  into  a 
phase  of  increased  irritability  (positive  modification)  it  is 
difficult  to  understand  the  precepts  so  often  given  that  "  the 
positive  pole  acts  as  a  sedative,  the  negative  as  a  stimulant." 
Both  are  stimulants,  if  "  stimulation  "  there  be,  the  kathode 
more  so  than  the  anode ;  but  that  is  all,  and  I  demur  to  the 
charge  of  inconsistency  brought  by  Erb  against  those  who, 


IN   PHYSIOLOGY  AND   THERAPEUTICS.  41 

adopting  the  unipolar  method  for  purposes  of  diagnosis,  do 
not  carry  it  out  systematically  in  therapeutics.  A  further 
objection  to  the  electrotonic  system  of  electro-therapeutics  is 
that  in  the  only  instance  where  we  can  produce  pure  polar 
effects,  in  that  of  the  acoustic  nerve,  "  the  systematic  produc- 
tion of  an-  or  katelectrotonus,"  as  it  is  called,  has  not  proved  a 
success.  Indeed,  if  the  doctrine  were  true,  we  might  expect 
that  where  the  negative  pole  is  indicated  the  positive  would 
increase  the  mischief,  and  vice  versa.  It  is  a  matter  of  daily 
experience  that  hyperaesthesic,  hyperalgesic,  and  hypercinesic 
symptoms  are,  as  a  rule,  happily  influenced  by  the  one  pole  as 
by  the  other.  As  to  the  pretension  of  inducing  electrotonus  of 
the  brain,  spinal  cord,  and  vaso-motor  nerves  (katelectrotonus 
of  the  latter,  by  the  way,  to  produce  dilatation  of  the  arterioles), 
I  do  not  know  upon  what  physiological  evidence  it  rests,  nor 
even  what  the  expression  very  well  means. 

Though  the  unipolar  method  does  not  fulfil  therapeutically 
the  ambition  of  its  promoters,  its  adoption  has  led  to  most 
valuable  results  in  the  field  of  diagnosis,  and  I  am  the  more 
anxious  to  recognise  Brenner's  durable  services  in  this  respect 
that  I  have  been  led  to  stand  in  antagonism  to  his  other  views. 
Electro-diagnosis,  difficult  enough  on  this  unipolar  system, 
is  impossible  on  the  bipolar  method,  with  which  in  the  living 
subject  we  would  get  four  electrodes  to  the  same  nerve;  and 
the  bitterest  foes  of  the  new  system  have  been  obliged  to 
adopt  it,  though  not  always  with  the  best  grace.1  A  clear 
conception  of  the  physical  conditions  of  unipolar  stimulation 
is,  however,  necessary  for  the  rational  application  of  electrical 
tests,  and  I  am  not  without  hope  that  the  previous  remarks 
may  clear  up  certain  obscurities  hitherto  prevalent.2 

The  question  of  a  possible  influence  of  the  direction  of  the 
current  is  intimately  bound  up  with  that  of  the  density  of  the 
current.  On  this  point,  again,  much  useless  discussion  has 
been  expended.  Supposing  it  is  desired  to  estimate  how  much 
electricity  passes  through  the  sciatic  nerve  at  a  point  half 

1  Cf.  Benedikt,  «  Elektrotherapie,'  2nd  Ed.  1874. 

2  When  the  electrode  is  placed  on  the  abductor  indicis  near  its  insertion,  I  find 
that  A.C.C.  >  K.C.C.  The  same  phenomenon  occurs  in  other  pnrts,  and  is 
explainable  on  the  assumption  that  a  virtual  kathode  occurs  at  a  point  of  the 
muscle  more  excitable  than  the  point  of  application  of  the  anode. 


42      CONDITIONS  OF  THE  UNIPOLAR  STIMULATION,  ETC. 

way  between  the  glutaeal  region  to  the  popliteal  space  when 
the  electrodes  with  a  current  of  say  twenty  millevebers  *  are 
placed  in  these  positions,  all  we  shall  have  to  do  is  to  divide 
the  diameter  x  specific  resistance  of  the  nerve  by  the  dia- 
meter x  mean  specific  resistance  of  the  tissues  of  the  thigh. 

The  equation  ^ ^  =  ^  gives  us  the  result.     Assuming 

D1  =  12  and  K1  =  5,  when  D  and  R  are  taken  at  unity  this 
would  give  us  ^Vth  of  the  current  as  passing  through  the 
nerve  at  the  point,  which  is  a  very  high  estimate.  This  rough 
calculation  gives  us  at  least  as  accurate  quantitative  results  as 
the  galvanometric  experiments  of  Burkhardt2  and  others, 
since  the  unknown  relation  between  the  resistance  of  the 
piece  of  nerve  included  between  the  needles  and  that  of  the 
galvanometer  used  can  hardly  be  determined.  This  is  not  the 
place  to  discuss  the  arguments  adduced  by  those  who  uphold 
the  influence  of  the  direction  of  the  currents  on  the  various 
tissues.3  They  cannot  escape  the  objections  deduced  from  the 
fact  of  a  peripolar  direction  of  the  current  in  the  nerve  and 
from  the  great  diffusion  of  the  current  in  the  interpolar 
region  ;  it  is  only  within  a  short  radius  of  each  electrode  that 
the  density  is  sufficiently  great  to  produce  physiological 
effects.  And  though  the  therapeutical  conditions  drawn  from 
the  electrotonic  influence  of  the  poles  are  not  justified,  it  has 
yet  to  be  shown  that  the  very  weak  currents  which  traverse 
the  tissues  at  a  distance  from  the  electrodes  have  any  curative 
power,  apart  from  any  demonstrable  physiological  action. 
This  supposition  is,  of  course,  within  the  range  of  possibility  ; 
but  the  partisans  of  direction-influence  have  hitherto  produced 
no  proof  that  their  results  do  not  depend  from  the  relative 
position  of  the  poles.  The  discussion  of  this  point  will  be  best 
deferred  to  another  occasion. 

If  these  pages,  as  I  hope,  have  shaken  one  of  the  many 
Idola  Speeds  of  electro-therapeutics,  and  disposed  of  some  of 
the  loose  talk  and  thought  so  rife  in  the  literature  of  the 
subject,  my  object  is  fulfilled. 

1  De  Watteville,  '  Practical  Introduction  to  Medical  Electricity,'  chap.  i.     A 
current  of  20  millivebers  would  be  given  liere  by  about  40  Daniells. 
'-'  "  Die  polare  Methoile,"  '  Deutsche*  Archiv,'  1870. 
3  Oaiinus  and  Legrof,  'Traitc  d'filectricite'  uie'ilicalc,'  Paris,  1872. 


ANATOMY  AND  PHYSIOLOGY  OF  THE  CHORDA 
TYMPANI  NERVE. 

BY   HORATIO   R.    BIGELOW,   M.D.,   WASHINGTON,   U.S.A. 

A  series  of  experiments,  extending  over  a  number  of  months, 
may,  perhaps,  give  me  a  right  to  be  heard  upon  the  question 
of  the  "  Anatomy  and  Physiology  of  the  Chorda  Tympani." 
It  was  not  without  much  diffidence  and  a  measure  of  embarrass- 
ment that  I  published,  in  June,  1879,  in  the  'Archives  of 
Medicine '  (New  York),  the  conviction  which  I  had  reached 
that  the  chorda  tympani  is  not  a  branch  of  the  facial  proper, 
but  the  continuation  of  the  intermediary  nerve  of  Weisberg, 
and  that  its  physiology  differed  essentially  from  that  claimed 
for  it  by  writers  upon  special  subjects  of  scientific  medicine. 
I  felt  that  I  stood  alone  in  a  large  field  already  worn  by  the 
onward  march  of  physiologists,  and  that  while  their  footprints 
all  tended  in  the  same  direction,  mine  were  bending  in  a 
line  entirely  opposite.  But  now  that  Dr.  E.  C.  Spitzka  ('  New 
York  Medical  Record,'  Jan.  31st,  1880)  confirms  my  views  in 
greater  part  (his  objection  to  my  theory  of  the  function  of  the 
ganglion  will  be  noticed  farther  on),  I  feel  that  a  perfect 
vindication  of  such  discoveries  is  merely  a  question  of  time. 
Prof.  Sappey  ('  Traite  d'Anatomie  Descriptive  '),  than  whom 
few  write  more  clearly  and  forcibly,  and  whose  opinion  will 
always  command  profound  consideration,  writes :  "  La  dissec- 
tion unie  a  l'emploi  des  reactifs  demontre  entre  la  corde  du 
tympan  et  le  lingual  une  fusion  intime,  complete  fibrille  a 
fibrille  dans  toute  l'etendue  de  l'adossement  de  ces  nerfs;  a 
l'aide  de  ce  procede  on  tenterait  done  vainement  de  recon- 
naitre  le  mode  de  terminaison  de  la  corde  du  tympan."     It 


44  ANATOMY  AND  PHYSIOLOGY  OP  THE 

was  this  view  of  its  anatomy  which  first  led  me  to  inquire 
most  thoroughly  and  honestly  into  the  relations  of  the  chorda 
tympani,  and,  while  my  deductions  are  opposed  in  every 
particular  to  those  of  Prof.  Sappey  and  of  neuro-physiologists, 
yet  may  they  be  kindly  received,  and  substantiated  by  indi- 
vidual investigation.  In  the  '  New  York  Medical  Kecord '  for 
Jan.  17th,  1880,  I  published  the  following  conclusions : — 

1.  The  chorda  tympani  is  distinct  and  integral  throughout 
its  entire  length. 

2.  It  is  derived  from  the  nerve  of  Weisberg,  and  not  from 
the  facial. 

3.  Its  especial  sensory  function  is  derived  from  the  ganglion 
upon  the  nerve  of  Weisberg,  into  the  granular  protoplasm  of 
which  the  ultimate  fibrils  may  be  traced. 

4.  The  lingual  branch  of  the  fifth  presides  over  general 
sensibility  only.  Isolation  of  the  chorda  tympani  destroys  the 
sense  of  taste  in  the  anterior  two-thirds  of  the  tongue,  the 
fibres  undergoing  degeneration. 

5.  Section  of  the  lingual  destroys  sensibility,  but  only 
modifies  the  sense  of  taste ;  this  modification  being  due  exclu- 
sively to  the  branches  from  the  chorda  tympani. 

6.  Section  of  the  facial,  behind  the  origin  of  the  chorda 
tympani,  destroys  the  sense  of  taste  only  after  a  lapse  of  time  ; 
and  this  not  because  the  facial  at  this  point  contains  gustatory 
filaments,  but  because  the  nerve  is  cut  off  suddenly  from  its 
supply,  and  has  received  such  a  shock  that  it  undergoes  degene- 
tion.  If  the  chorda  tympani  be  drawn  out  at  the  point  where 
we  first  notice  its  filaments  of  origin,  and  divided,  the  sense 
of  taste  will  be  almost  entirely  destroyed.  If  the  nerve  of 
Weisberg  be  cut  in  the  aqueduct  behind  the  ganglion,  the 
sense  of  taste  is  lost.  From  which  it  may  be  inferred  that  the 
intermediary  nerve  is  continued  in  the  chorda  tympani,  and 
that  this  latter  is  a  carrier  of  the  sense  of  taste  from  the  cells 
in  the  intumescentia  gangliformis. 

The  differentiation  of  the  intermediary  nerve  and  the  main 
trunk  is  attended  with  the  utmost  difficulty,  and  can  be 
effected  only  by  the  use  of  reagents,  "  teasing  "  all  the  fibrils 
under  a  good  lens  mounted  upon  a  tripod.  In  this  way  the 
chorda  tympani  may  be  separated  from  the  lingual  and  followed 


CHORDA  TYMPANI  NERVE.  45 

up :  the  terminal  filaments  expanding  into  the  taste  cells  of 
the  beakers,  the  bulbous  expansion  at  the  end  being  identical 
with  the  transparent  nuclei.  In  the  same  way,  by  using  a 
power  of  1000  diam.,  we  may  trace  into  the  intumescentia 
gangliformis  the  nerve  fibrils  of  the  intermediary  nerve  in  the 
processes  of  the  ganglion  at  their  junction  with  the  cell,  and 
these  may  be  traced  into  the  granular  protoplasm.  From 
Dr.  Spitzka's  note  in  the  '  New  York  Medical  Record '  of 
January  31st,  I  may  be  allowed,  for  purposes  of  discussion,  a 
liberal  quotation : — 

"I  am  able  to  add  an  important  confirmatory  observation 
to  those  published  by  Dr.  Horatio  R.  Bigelow  in  the  '  Record,' 
favouring  the  view  that  the  chorda  tympani  nerve  is,  after  all, 
not  a  branch  of  the  facial  proper,  but  the  continuation  of  the 
nervus  intermedins  of  Weisberg.  It  is  well  known  that  this 
latter  nerve  is  entirely  distinct  from  the  facial  at  the  origin 
from  the  medulla  oblongata.  In  numerous  transverse  micro- 
scopic sections  of  human  and  animal  peduncular  tracts,  I 
have  found  that  the  fibres  of  the  nervus  intermedius  have 
no  connection  with  the  facial  nerve  nuclei.  Their  central  ter- 
mination lies,  in  fact,  in  lower  altitudes ;  that  is  to  say,  while 
the  facial  nuclei  are  situated  within  the  lower  pons  margin, 
the  nucleus  of  the  nerve  of  Weisberg  lies  strictly  within  the 
limits  of  the  medulla  oblongata  in  the  level  of  the  superior 
auditory  nucleus.  The  gray  origin  of  the  nerve  of  Weisberg 
is  diffuse,  and,  in  the  strict  sense  of  the  term,  cannot  be  called 
a  nucleus  for  that  reason.  On  examining  its  relations  more 
closely,  we  find  that  it  does  not  correspond  to  the  motor  gray 
column  of  the  medulla,  but  to  an  ideal  continuation  of  the 
gelatinous  column  of  the  trigeminus  region ;  in  other  words, 

it  originates  in  the  sensory  gray  column  of  the  medulla 

Dr.  Bigelow  makes  one  statement  to  which  I  must  take  ex- 
ception. He  attributes  the  sensory  function  of  Weisberg's 
nerve  to  a  ganglion  on  the  nerve.  It  is  generally  conceded 
that  peripheral  ganglia  are  obscure  in  their  function,  and  that 
the  function  of  a  cerebro-spinal  nerve  is  determined  by  its 
central  connections." 

This  confirmation,  in  part  at  least,  of  my  own  views  was 
most   opportune.     It  was   gratifying   to   be   sustained   in   so 


46  ANATOMY   AND   PHYSIOLOGY   OP  THE 

important  a  matter  by  one  so  skilled  in  investigation  as 
Dr.  Spitzka  is  known  to  be.  Unquestionably  it  is  a  fact  that 
the  consensus  of  medical  opinion  concedes  that  the  function 
of  a  cerebro- spinal  nerve  is  determined  by  its  central  connec- 
tions, rather  than  by  peripheral  ganglia.  But  such  concession 
is  due  to  the  seduction  of  pleasant  theorizing  rather  than  to 
absolute  demonstration.  No  one  has  attempted  a  logical 
explanation  of  the  functions  of  the  peripheral  ganglia,  and 
their  existence  upon  sensory  nerves  seems  to  be  ignored  in 
the  discussion  of  the  characteristic  nerve  function.  It  may 
or  may  not  be  true  that  the  functions  of  all  cerebro-spinal 
nerves  are  determined  by  a  central  connection ;  we  have  no 
demonstrable  proof  for  or  against  the  theory.  In  all  exact 
physiological  inquiries,  as,  indeed,  in  all  inquiries  of  exact 
science,  we  must  be  governed  by  fact  rather  than  by  inference. 
I  doubt  exceedingly  if  the  chorda  tympani  is  made  sensory 
solely  through  its  central  connection.  I  can  make  no  absolute 
assertion,  because  experiments  upon  this  ganglion  are  sur- 
rounded with  almost  insurmountable  difficulty.  I  have  exposed 
it,  and  touched  it  with  acetic  acid  ;  but  a  microscopic  section 
showed  that  the  chemical  action  had  extended  along  the 
nerve  fibre,  and  that  it  had  lost  its  normal  characteristics.  I 
then  tied  the  nerve  with  a  small  silk  thread  behind  the 
ganglion,  and  irritated  the  ganglion  with  the  electrode  of  a 
small  Gaiffe  battery  ;  the  sense  of  taste  persisted  for  two  hours 
and  a  half,  so  that  there  must  have  been  reserve  force  at  least 
within  the  ganglion.  If  it  were  possible  either  to  extirpate 
the  ganglion,  or  to  destroy  it  without  resultant  injury  to 
nerve  fibre,  the  question  might  be  definitely  settled ;  and  to 
this  end  I  have  called  to  its  fullest  extent  upon  the  little 
inventive  genius  I  may  possess,  but  so  far  unavailingly.  I  do 
not  maintain  that  the  intumescentia  gangliformis  in  question 
is  capable  of  originating  the  sensory  function,  although  in 
some  cases  of  paralysis  it  would  seem  to  possess  such  a  power ; 
but  one  of  my  experiments  has  demonstrated  that  it  does  act 
either  as  a  storehouse  or  as  a  generator.  The  ganglion,  too, 
serves  to  differentiate  with  exquisite  precision  between  the 
effects  of  sapid  substances,  whose  appreciation  is  governed 
by  a  central  connection ;  the  psychic  phenomena  of  the  cord 


CHORDA  TYMPANI  NERVE.  47 

contrasting  strongly  with  the  physical  manifestation  of  the 
ganglion. 

In  closing  this  paper,  I  may  be  allowed  to  refer  once  more 
to  my  communication  in  the  '  Eecord.'  "  The  difficulty  of 
noting  the  impairment  of  taste  is  exceedingly  great,  and 
one  will  fail  often  before  arriving  at  satisfactory  results.  The 
shock  following  a  section  of  the  nerve  within  the  cranial 
cavity  necessarily  modifies  exact  conclusions,  and,  as  Flint 
very  justly  observes  ('  Text-Book  of  Human  Physiology,'  p. 
761),  '  We  must  remember  the  difficulty  of  such  observations, 
and  we  are  to  rely  mainly  upon  the  unmistakable  phenomena 
noted  in  cases  of  affection  of  the  chorda  tympani  in  the  human 
subject.'  Paralysis  of  the  facial,  behind  the  origin  of  the 
chorda  tympani,  is  attended  with  loss  of  taste  in  the  anterior 
two-thirds  of  the  tongue.  But  this  is  not  due,  as  I  believe, 
to  the  existence  of  gustatory  filaments  in  the  facial  itself,  but 
to  the  fact  that  the  transmitted  shock  is  so  great  as  to  destroy 
the  function  of  the  ganglion  upon  the  nerve  of  Weisberg,  and 
in  this  way  inhibit  the  special  characteristic  of  the  chorda 
tympani  as  a  carrier  of  the  sense  of  taste.  The  sensibility  of 
the  tongue  remains,  because  it  derives  its  sensory  power  from 
a  different  source ;  the  cells  furnishing  the  lingual  branch  of 
the  fifth  are  not  interfered  with  in  such  cases  of  paralysis. 
It  is  a  fact,  however,  that  sensibility  is  often  modified,  owing 
to  the  inability  of  the  nerve  fibre,  by  reason  of  a  degeneration 
resultant  upon  shock,  to  carry  the  sensation.  If  we  isolate, 
so  far  as  it  may  be  possible  to  do,  with  a  proper  regard  for  the 
life  of  the  animal,  both  the  chorda  tympani  and  the  interme- 
diary nerves,  the  sense  of  taste  becomes  greatly  modified,  and 
after  a  time  almost  entirely  lost,  the  feeble  sense  remaining 
being  due  to  the  fibrils  which  it  is  impossible  to  divide.  If 
there  were  essential  gustatory  filaments  in  the  facial,  the  sense 
of  taste  would  persist  in  a  greater  degree  than  it  does  after 
division  of  these  two  nerves.  If  we  are  to  study  the  functions  of 
the  chorda  tympani  from  its  action  in  those  morbid  conditions 
affecting  it,  the  nature  of  the  shock,  as  well  as  the  resultant 
influence  engendered  by  contiguity  of  structure  or  by  actual 
contact,  must  never  be  lost  sight  of.  Nerves,  themselves  unin- 
jured, may  suffer  in  their  action  by  transmitted  influences." 


48  ON   THE   PARALYSIS   WHICH   RESULTS   FROM 


ON    THE    PARALYSIS    WHICH    RESULTS    FKOM 
ANGULAR  CURVATURE  OF  THE  SPINE. 

BY  JOHN   DUNCAN,   M.D., 

Surgeon  to  the  Edinburgh  Royal  Infirmary,  Lecturer  on  Surgery. 

Cases  of  caries  may  be  divided  into  two  classes,  of  which  the 
types  are  very  distinct,  although  they  shade  into  one  another 
with  an  infinite  gradation.  In  the  one  class  are  those  in  which 
the  disease  has  a  constitutional,  in  the  other  those  in  which  it 
has  an  external  etiology. 

In  the  spine  it  appears  to  me  that  this  distinction  is  as 
distinctly  marked  as  in  other  parts  of  the  body.  Patients  of 
the  first  group  have  the  strumous  or  tubercular  diathesis ; 
near  relations  have  had  phthisis,  or  white  swelling,  or  glan- 
dular inflammations.  They  have  themselves  the  general 
characters  of  the  diathesis,  or  have  suffered  from  its  patho- 
logical manifestations.  They  have  spat  blood  or  had 
pleurisy.  They  have  scars  in  the  neck,  or  tubercle  in  the 
lungs,  or  chronic  joint-disease.  In  short,  the  personal  or 
family  history  is  bad. 

In  such  cases  the  angular  curvature  is  rapid  in  its  forma- 
tion. Psoas,  or  lumbar,  or  cervical  abscesses  form  early  in  the 
disease.  The  patients  sink  from  hectic  or  from  amyloid 
degeneration  of  the  liver  and  kidney.  If  paralysis  make  its 
appearance  it  is  commonly  from  pressure  on  the  cord,  and  is 
sometimes  suddenly  fatal  in  the  cervical  region. 

Patients  in  the  second  class  have  generally  some  distinct 
history  of  serious  injury.  Their  appearance  is  robust  and 
healthy.  The  family  and  personal  history  is  free  from  trace 
of  strumous  disease.     Abscess  is  comparatively  a  rare  occur- 


ANGULAR   CURVATURE   OF  THE  SPINE.  49 

rence.  Paralysis,  on  the  contrary,  appears  soon.  Sometimes 
it  precedes  the  projection  of  the  spines,  and  is  accompanied 
only  by  tenderness  on  pressure  or  percussion,  or  on  the  appli- 
cation of  heat  or  cold.  The  patients  die  from  the  effects  of 
the  paralysis,  and  if  there  be  no  paralysis  the  disease  runs  an 
exceedingly  slow  course.  While  the  strumous  form  attacks 
the  child  or  the  young  adult,  this  variety  is  more  common 
in  middle  or  advanced  life. 

The  paralysis  is  peculiar.  It  confines  itself  specially  to  the 
motor  track  of  the  cord.  Sensation  is  rarely  affected.  The 
motor  paralysis  is  often  of  the  spastic  form,  and  is  sometimes 
very  extreme.  The  lower  limbs  are  most  apt  to  become  para- 
lysed. The  bladder  and  bowels  retain  their  normal  functions, 
or  are  only  temporarily  disturbed.  Trophic  changes  also  are 
infrequent. 

I  have  been  much  struck  by  the  distinct  way  in  which  all 
these  peculiarities  come  out  in  the  series  of  cases  which  I 
shortly  append.  They  are  those  which  have  been  resident  in 
the  wards  under  my  care  during  the  last  two  years,  having 
been  admitted  for  the  purpose  of  opening  the  abscess  or  for 
observation.  Many  other  cases  of  the  strumous  variety  were 
out-patients  during  the  same  period,  but  I  have  not  met  with 
any  other  examples  of  paralysis. 

I. — Jessie  S.,  set.  31,  married,  admitted  18th  December, 
1878.  Sallow  and  thin.  Her  mother  died  of  phthisis,  and 
her  father  died  young.  She  is  very  subject  to  indigestion. 
About  4  years  ago  she  felt  pain  in  the  back  after  delivery  of 
her  second  child.  She  was  unable  to  carry  it  about,  and  has 
not  been  free  from  the  pain  since  that  time.  Three  months 
ago  swelling  appeared  about  Poupart's  ligament,  which  was 
opened.  There  is  prominence  of  the  11th  and  12th  dorsal 
vertebra?.  A  plaister  jacket  was  applied.  In  June,  1879,  the 
discharge,  though  slight,  still  continued,  and  there  was  little 
alteration  in  the  general  condition. 

II.— Harriet  M.,  aet.  23,  single,  admitted  19th  June,  1878. 

History.  Family :  Mother  and  two  sisters  died  of  phthisis. 
A  brother  had  an  abscess  in  his  side,  which  has  now 
healed. 

Personal :  Amputation  of  the  third  toe  of  the  left  foot  was 

VOL.   III.  E 


50  ON  THE   PAEALYSIS   WHICH   RESULTS   FROM 

performed   a  year  ago,  on  account  of  caries.     There  is  now 
caries  of  the  metacarpo-phalangeal  joint  of  the  left  thumb. 

There  is  lumbar  abscess,  and  projection,  and  pain  on  pres- 
sure over  the  4th  and  5th  dorsal  vertebrae. 

The  abscess  was  aspirated  and  a  jacket  applied.  When  last 
heard  of,  the  patient  was  progressing  favourably. 

It  would  be  tedious  to  enter  into  the  history  of  common 
cases  of  which  these  may  be  taken  as  the  types.  In  all  the 
treatment  was  either  aspiration  or  antiseptic  opening  of  the 
abscess,  with  the  use  of  the  plaister  jacket.  I  enumerate  only 
and  mention  the  salient  points. 

III. — Duncan  C,  set.  22.  Psoas  abscess  and  angular  projec- 
tion of  the  10th  and  11th  dorsal  vertebrae.  Has  twice  had 
inflammation  of  the  lungs,  and  the  present  signs  of  phthisis 
are  distinct.     A  brother  had  white  swelling  of  the  knee. 

IV.— John  L.,  set.  23,  admitted  7th  November,  1879.  Psoas 
abscess  and  angular  curvature  of  6th,  7th,  and  8th  dorsal 
vertebrae.  He  refers  his  disease  to  a  fall  downstairs,  but  it  is 
clearly  ascertained  that  the  projection  existed  before  the  fall, 
although  the  pain  was  thereby  increased.  Some  years  ago  he 
had  abscesses  in  the  right  arm,  which  lasted  several  months. 
His  mother  died  after  child-birth. 

V. — A.  D.,  aet.  3,  admitted  January,  1880.  Double  psoas 
abscess  and  excessive  curvature  in  lower  dorsal  region.  Two 
cases  of  phthisis  in  the  family.  The  treatment  is  by  double 
extension. 

VI. — Patrick  D.,  aet.  31.  Pale,  thin,  and  strumous-looking. 
Lumbar  abscess  and  angular  curvature  of  7th  dorsal  spine. 
Knows  nothing  of  family  history.  No  injury  or  previous 
illness. 

VII. — William  S.,  aet.  25.  Lumbar  abscess  and  projection 
of  7th  and  8th  dorsal  vertebrae.  No  history  of  injury.  A 
brother  has  scars  in  his  neck. 

VIII. — John  N.,  aet.  15.  Caries  of  3rd  and  4th  cervical 
vertebrae.  Father  died  of  phthisis.  In  this  case  I  opened  a 
retro-pharyngeal  abscess  by  the  method  advocated  by  Mr. 
Hilton  and  Mr.  Chiene.  Unfortunately  it  opened  also  into 
the  pharynx  a  week  afterwards,  and  consequently  became 
septic.     He  comes  in  to  show  himself  occasionally,  and  is 


ANGULAR  CURVATURE   OF   THE   SPINE.  51 

getting  much  emaciated  from  the  discharge,  which  has  now 
been  going  on  for  more  than  a  year.  He  has  also  had  several 
fits.  The  epilepsy,  however,  I  believe  to  be  connected  with 
carie-necrosis  of  the  right  temporal  bone  in  the  mastoid  region, 
which  is  considerable  in  extent. 

In  none  of  these  cases  was  there  the  slightest  paralytic 
symptom. 

The  following  cases  illustrate  the  other  form  of  disease  of 
the  vertebral  bodies  to  which  I  have  referred. 

I. — The  first  case  which  attracted  my  notice  was  that  of  a 
miner,  aet.  23,  whom  Professor  Saunders  asked  me  to  see  in  his 
ward.  There  was  marked  angular  curvature  of  the  lowest 
cervical  and  upper  dorsal  vertebrae,  with  an  unusual  amount  of 
inclination  to  the  left.  He  said  he  had  been  in  the  habit  of 
carrying  exceedingly  heavy  weights  on  the  left  shoulder,  and 
on  several  occasions  was  conscious  of  having  strained  the  parts. 
In  fact,  he  felt  assured  that  he  had  immediately  produced  the 
lump  in  one  of  his  "  lifts."  There  was  considerable  pain  on 
pressure.  He  had  spastic  paralysis  of  the  lower  extremity  to  an 
extreme  degree.  The  tendon  reflex  was  enormously  exagge- 
rated, and  he  was  unable  to  walk  more  than  a  few  paces,  even 
with  assistance,  on  account  of  the  spasmodic  jerking  of  his 
limbs.  I  applied  the  plaister  jacket,  with  jury-mast  and  elastic 
support  for  the  head.  He  at  once  began  to  improve.  He  still 
after  a  year  continues  to  wear  the  apparatus,  and  sends  me 
word  that  he  can  go  about  as  well  as  ever,  but  his  legs,  he 
thinks,  "  make  him  walk  faster  than  he  would  otherwise  do." 

II.— John  K.,  aet.  27.  Admitted  December  7th,  1878. 
Family  and  personal  history  good. 

A  year  before  admission  he  fell  from  a  ladder  while  carrying 
a  heavy  load  of  lead.  He  injured  his  back,  and  thereafter  wore 
a  belt  for  two  months  before  he  observed  the  projection  of  his 
spine.  The  5th,  6th,  and-  7th  dorsal  vertebrae  are  promi- 
nent. He  has  distinct  loss  of  power  in  the  legs,  which  he 
moves  in  a  jerking  manner.  The  patellar  tendon  reflex  is  in- 
creased. Sensation  is  normal.  He  had  a  plaister  of  Paris 
jacket  applied.  The  pain  and  paralysis  much  improved  when 
he  was  last  heard  of,  six  months  after  leaving.  He  then  showed 
himself  for  renewal  of  the  jacket. 

e  2 


52  ON   THE   PARALYSIS    WHICH   RESULTS   FROM 

III.— John  D.,  miner,  set.  53.  Admitted  May  6th,  1879. 
The  family  and  personal  history  are  unexceptionable.  He  is 
not  aware  of  any  special  injury,  but  says  that  he  has  often  felt 
his  occupation  a  strain  on  his  back. 

He  has  felt  pain  in  his  back  for  about  a  year,  and  noticed 
the  projection  of  the  4th  dorsal  spine  several  months  ago. 
For  three  or  four  weeks  his  legs  have  been  getting  weaker. 
He  is  now  barely  able  to  walk  with  assistance,  and  his  legs 
have  a  great  tendency  to  cross  in  doing  so.  The  tendon  reflex 
is  much  increased  in  every  action.  Sensation  is  slightly  duller 
than  normal  in  the  lower  limbs.  The  bowels  are  sluggish.  A 
jacket  was  applied,  but  fitted  badly,  and  during  the  ten  days 
he  was  in  the  infirmary  he  rapidly  deteriorated.  At  the  end 
of  that  time  he  was  quite  unable  to  stand  alone.  A  better 
jacket  was  adjusted,  and  he  at  once  began  to  improve.  He 
returned  January,  1880,  to  ask  whether  he  might  resume  light 
work.  He  could  then  walk  without  the  least  apparent  impedi- 
ment. 

IV. — Henry  B.,  set.  13.  The  family  history  is  good.  There 
is  no  history  of  injury.  The  3rd,  4th,  and  5th  dorsal  spines 
project.  The  disease  has  been  in  progress  for  three  years,  but 
there  is  no  sign  of  abscess.  On  the  other  hand,  the  spastic 
paralysis  is  so  marked  that  he  cannot  walk  even  with  assist- 
ance. He  has  had  a  jacket  on  now  several  months,  but 
although  the  local  pain  is  relieved  the  paralysis  is  steadily 
getting  worse. 

V.— Thomas  B.,  miner,  «t.  32.  Admitted  6th  Feb.  1880,  a 
robust-looking  man  ;  family  history  perfectly  good. 

As  a  boy  he  pushed  waggons  in  the  mine  by  laying  his 
head  against  them,  and  remembers  straining  his  neck  when  he 
was  seventeen  so  severely  that  the  pain  lasted  for  a  year, 
during  which  he  could  not  work.  Since  then  the  neck  has 
been  stiff.  Six  years  ago  he  lost  the  power  of  his  fingers,  and 
shortly  afterwards  of  his  legs.  The  fingers  are  now  nearly 
well.  The  legs  have  got  gradually  worse,  and  he  is  now  quite 
unable  to  walk.  He  has  on  several  occasions  had  difficulty  in 
passing  water.  This  was  much  relieved  by  the  application  of 
a  blister  to  the  nape  of  the  neck.  The  actual  cautery  has 
been   used   three   times,  twice   with   decided    but  temporary 


ANGULAR   CURVATURE   OF   THE    SPINE.  53 

improvement  in  the  paralysis.  Sensation  is  not  affected ;  he 
can  move  his  limbs  pretty  freely  in  bed,  but  cannot  support 
himself.  Tendon  reflex  is  increased.  The  neck  is  shortened, 
and  quite  stiff.  There  is  no  abscess.  The  plaister  jacket  was 
applied  9th  Feb.  1880. 

VI.— William  B.,  miner,  set.  38.  Admitted  July,  1879. 
Family  history  good.  No  previous  illness.  He  once  broke 
his  thigh,  and  has  had  several  severe  injuries  to  the  back,  but 
cannot  attribute  his  present  illness  to  any  one  in  particular. 
He  has  had  pain  in  the  back  for  two  years,  but  left  off  work 
only  five  weeks  ago>  when  the  doctor  observed  the  prominence 
of  the  4th  dorsal  spine.  The  patient  walks  with  great  diffi- 
culty, and  has  all  the  symptoms  of  spastic  paralysis.  The 
leg  continues  to  twitch  for  a  considerable  time  after  the  stroke 
on  the  tendon.  A  plaister  jacket  was  applied,  when  he  im- 
mediately began  to  improve.  It  was  renewed  in  Jan.  1880, 
when  the  paralysis  was  found  to  have  almost  disappeared. 

VII. — James  McGlore,  aet.  37,  miner.  Patient  of  Dr.  Muir- 
head's.  The  family  history  is  unexceptionable.  Four  years  ago, 
just  before  his  illness  commenced,  he  slept  out  all  night  while 
intoxicated.  For  two  years  he  had  paralysis  and  pain  in  the 
back,  but  no  projection.  The  3rd  dorsal  spine  is  now  pro- 
minent. The  legs  are  constantly  and  rigidly  contracted, 
flexed,  and  crossed.  If  the  great  toe  be  forcibly  flexed  the 
limb  is  involuntarily  straightened,  but  soon  recovers  its 
abnormal  posture.  Two  years  ago  he  had  some  difficulty 
in  urination  and  defalcation,  but  it  speedily  passed  off.  Double 
extension  was  used,  "and  the  actual  cautery  applied,  but 
without  benefit. 

VIII.— W.  M.,  «t.  38.  Admitted  Feb.  1880.  The  family 
and  personal  history  is  good.  He  has  met  with  no  serious 
injury.  Pain  in  the  back  came  on  about  six  months  ago,  with 
projection  of  12th  dorsal  spine.  He  has  distinct  spastic 
paralysis  with  increased  tendon  reflex.  There  is  no  abscess. 
A  plaister  jacket  has  been  applied. 

The  following  cases  differ  from  the  others  in  several  im- 
portant features,  and  may  be  regarded  as  links  in  the  chain 
which  unites  the  two  classes  together  : — 

I. — James  H.,  »t.  42.    Patient  of  Dr.  Muirhead's.   A  brother 


54  ON  THE   PAEALYSIS  WHICH   RESULTS   FROM 

died  of  phthisis.  The  disease  began  four  years  ago,  without 
known  cause.  Pain  in  and  projection  of  the  3rd,  4th,  and 
5th  dorsal  spines  were  at  once  observed,  and  an  abscess  soon 
afterwards  formed  a  little  lower  down,  which  still  continues  to 
discharge.  In  August,  1879,  he  began  to  feel  loss  of  power 
in  the  limbs,  and  abdominal  constriction.  He  has  now  a 
trailing  gait.  The  muscles  are  flaccid,  and  without  spasm. 
The  reflex  action  is  diminished.  The  patellar  tendon  reflex  is 
slightly  increased,  especially  on  the  left  side. 

II. — Patrick  L.,  set.  38,  labourer.  Admitted  July,  1879. 
Family  history  good.  He  met  with  a  severe  injury  to  the 
back  by  falling  from  a  ladder  a  year  ago,  and  immediately 
afterwards  a  gradually  increasing  projection  of  the  5th  dorsal 
spine  commenced,  followed  shortly  by  an  abscess  a  little  lower 
down.  There  is  no  paralysis.  The  abscess  was  opened  anti- 
septically,  and  he  is  now  progressing  favourably. 

These  cases,  I  think,  mark  very  clearly  the  distinction  I 
have  drawn  between  the  strumous  form  of  the  disease  and  that 
which  has  its  most  striking  analogy  in  the  chronic  interstitial 
absorption  of  the  neck  of  the  thigh-bone,  which  in  adults  so 
often  follows  severe  injury.  It  will  be  noted  that  in  this 
latter  variety,  to  which  I  specially  wish  to  direct  attention, 
there  was  in  almost  every  case  a  distinct  history  of  injury,  or 
of  such  an  occupation  as  throws  great  strain  upon  the  vertebral 
column.  In  the  strumous  the  disease  may  have  its  starting- 
point  in  an  injury,  but  most  often  the  history  is  an  after- 
thought, or  the  projection  is  said  to  have  come  of  itself. 
The  other  peculiarities  of  caries  siccuin,  to  which  I  have 
already  referred,  are  also  remarkably  illustrated  by  these  cases. 
Of  all  these  features  the  most  singular  seems  to  me  the  fre- 
quency with  which  it  is  accompanied  by  paralysis.  I  have  no 
doubt  that  my  experience  of  these  two  years  has  been  unusual. 
Dr.  Saunders's  patient,  an  Ayrshire  miner,  was  so  greatly 
benefited  by  treatment  that  the  patients  T.  B.  and  J.  D.,  also 
miners  in  the  same  district,  were  induced  to  come  by  the 
report  of  his  case.  Still  it  is  plainly  much  more  frequent  in 
this  than  in  the  strumous  caries. 

It  will  be  noted  that  the  paralysis  was  almost  exclusively 
motor.     It  is  a  feature  of  all  spinal  disease  that  special  tracts 


ANGULAR   CURVATURE   OF   THE   SPINE.  55 

of  the  cord  should  be  very  accurately  marked  out  by  it. 
AVhatever  the  explanation,  it  appears  to  characterise  this 
consecutive  paralysis  as  distinctly  as  the  idiopathic.  One  can, 
to  a  certain  extent,  understand  how  the  motor  portions  of  the 
cord  are  most  prone  to  become  inflamed  in  consequence  of 
caries  of  the  bone.  But  it  is  more  difficult  to  determine  why 
the  spastic  form  of  paralysis  should  so  greatly  preponderate. 
In  Dr.  Saunders  and  Dr.  Muirhead's  patients  the  disease  was 
severe  and  typical ;  in  others  it  was  unmistakable,  though  not 
so  far  advanced.  The  cases  are  clear  examples  of  those 
secondary  degenerations  which  Tiirck  and  Charcot  have  de- 
scribed. 

The  success  of  the  treatment  has  been  gratifying.  Five 
cases  have  been  sufficiently  long  under  treatment  to  allow  of  a 
judgment  being  formed.  Three  of  these  have  been  practically 
cured,  although  they  still  wear  the  apparatus.  In  one  case  no 
benefit  has  resulted  from  the  jacket.  In  another  the  jacket 
was  not  applied  as  it  had  previously  been  tried  in  Glasgow. 
For  him  I  used  the  actual  cautery  without  effect,  and  perma- 
nent extension  in  bed  from  head  and  feet,  was  applied,  but 
not  persisted  in  from  the  annoyance  and  inconvenience  it 
occasioned. 

It  is  plain  that  in  this  chronic  ostitis,  as  in  the  same  disease 
in  other  parts  of  the  body,  our  local  treatment  is  twofold,  rest 
and  counter-irritation.  These  cases  illustrate  the  advantage 
that  may  be  gained  from  both.  The  miner,  Thomas  B.,  was 
benefited  on  many  occasions  by  blisters,  and  twice  by  actual 
cautery.  Unfortunately  the  relief  was  not  permanent.  I  fear 
that  if  counter-irritation  be  used  alone  this  is  the  usual  result, 
whether  blisters,  seton,  or  cautery  be  the  means  employed. 
To  do  much  good  they  require  persistence,  and  with  persist- 
ence comes  a  time  when  their  beneficial  effect  ceases.  They 
must  be  combined  with  rest.  Now  rest  for  the  spinal  column 
is  difficult  to  procure.  It  implies  abrogation  both  of  motion 
and  of  pressure.  This  may  be  attempted  in  two  ways ;  by 
retention  in  bed,  or  by  the  use  of  apparatus.  Until  Mr.  Sayre 
made  known  the  value  of  the  plaister  jacket,  the  inefficiency 
of  apparatus  was  such  that  recumbency  was  the  recognised 
treatment  for  disease  of  the  spinal  column,  at  leasl  in  the 


56  PARALYSIS  FROM  CURVATURE  OF  THE  SPINE. 

Edinburgh  school.  But  if  the  objects  aimed  at  by  apparatus 
be  attained,  its  other  advantages  are  manifest ;  and  I  believe 
that  they  are  in  great  measure  so  attained  by  the  jacket.  It 
does  not  take  off  perpendicular  pressure  so  completely  as 
recumbency  does.  If  the  jacket  alone  be  used,  the  body  tele- 
scopes gradually  into  it,  and  the  plaister  sinks  en  masse  unless 
it  be  very  accurately  adjusted  to  the  pelvis.  If  the  disease  be 
at  or  above  the  6th  dorsal  vertebra,  it  is  essential  that  the 
jury-mast  be  also  applied,  and  the  head  attached  to  it  by 
elastic  bands  which  act  much  better  than  rigid  straps.  But 
while  apparatus  may  not  thoroughly  relieve  pressure,  at  least 
it  very  effectively  restrains  motion,  which  mere  recumbency 
cannot.  Even  the  actions  of  breathing  are  diverted  from  the 
ribs. 

It  is  not  essential  that  the  material  be  plaister  of  Paris. 
That  is  usually  most  convenient.  But  I  have  moulded  very 
comfortable  jackets  from  the  poroplastic  splint  material,  and 
paraffin  is  light  and  easily  applied  in  children,  though  not  so 
durable  and  rigid  in  the  adult. 

The  conclusions  to  be  drawn  from  these  cases  are : 

1st.  That  there  are  two  distinct  varieties  of  inflammation 
which  attack  the  bodies  of  the  vertebrae. 

2nd.  That  in  strumous  cases  there  is  comparatively  little 
tendency  to  affection  of  the  spinal  cord. 

3rd.  That  in  chronic  interstitial  absorption  there  is  a  great 
tendency  to  paralysis,  which  presents  the  usual  characters  of 
what  has  been  termed  "  pressure  myelitis,"  with  its  secondary 
degenerations. 

4th.  That  this  paralysis  may  often  be  cured  by  rest  and 
counter-irritation. 


ON  SOME  VAEIETIES  OF  CERVICAL  PARAPLEGIA. 

BY   THOMAS   BUZZARD,   M.D., 

Physician  to  the  National  Hospital  for  the  Paralysed  and  Epileptic. 

It  has  happened  to  me  to  have  under  observation,  more  or 
less  recently,  several  cases  of  the  condition  to  which  the  term 
"  cervical  paraplegia  "  has  been  (first  of  all,  I  think,  by  Sir 
William  Gull)  applied.  In  these  cases  paralysis,  usually  both 
of  motion  and  sensation,  has  affected  more  or  less  completely 
all  four  extremities,  the  upper  in  excess,  and  the  circumstances 
by  which  the  paralysis  has  been  characterised  have  enabled 
one  without  difficulty  to  localise  the  lesion  in  the  upper  part 
of  the  spinal  cord.  In  only  one  case,  however,  did  the  result 
give  the  opportunity  of  confirming  the  diagnosis  by  a  post- 
mortem examination,  and  on  this  account  I  propose  to  relate 
this  example  first.  The  symptoms  during  life,  and  the  patho- 
logical appearances  after  death,  will  serve  to  throw  light  upon 
many  points  in  the  other  cases  described,  which  have  termi- 
nated in  a  greater  or  less  amount  of  recovery.  In  spite  of  the 
aid  thus  afforded,  it  will  be  found  that  although  the  locality  of 
the  lesion  can  usually  be  indicated  with  tolerable  confidence,  its 
nature  is  by  no  means  always  to  be  determined  with  equal 
certainty. 

Case  I. — Epileptic  seizures — incomplete  paralysis  of  arms  and 
legs ;  pseudo-neuralgic  pains ;  amyotrophy  ;  marked  improve- 
ment under  iodide  and  mercury  ;  relapse ;  apoplectic  seizure ; 
death.  Autopsy  : — hypertrophic  cervical  pachymeningitis  ; 
transverse  myelitis  ;  thickening  of  basilar  artery ;  thrombosis  ; 
cerebral  softening. 

The  patient,  S ,  was  a  clerk,  about  35  years  of  age,  living 

a  few  miles  from  town,  whom  I  visited  at  the  request  of  his 
employer,  on  July  14th,  1877.      He  was   below  the  middle 


58       ON   SOME   VARIETIES   OF   CEEVICAL   PARAPLEGIA. 

stature,  with  a  squint,  which  I  was  told  was  of  many  years 
standing.  He  presented  a  peculiarly  muddled  look,  and  a 
manner  so  confused  that  I  had  difficulty  in  obtaining  informa- 
tion from  him.  His  memory  appeared  to  be  very  bad.  From 
what  I  could  gather  then,  supplemented  by  later  information, 
his  family  history  was  as  follows.  His  father  died  at  38  years 
of  age,  in  a  lunatic  asylum ;  his  mother,  set.  50,  of  a  "  natural 
death ; "  she  drank.  He  had  never  had  any  brothers  or 
sisters. 

Personal  history. — The  patient  suffered  from  fits  in  his  infancy 
until  he  was  about  six  or  seven  years  old.  The  next  thing  one 
learnt  was  that  when  he  was  21  years  of  age  he  lost  the  sight 
of  each  eye  in  succession,  that  of  the  left  eventually  recovering. 
About  eight  or  nine  years  ago  he  had  a  venereal  ulcer,  which 
was  accompanied  by  two  suppurating  buboes,  for  which  he  took 
medicine  to  make  his  gums  sore.  His  employer  tells  me  that 
five  or  six  years  ago  S 's  eyes  were  "  bad  "  (interstitial  kera- 
titis ?),  so  that  he  had  to  be  off  work  for  six  months.  During 
the  last  year  he  had  had  five  or  six  fits,  of  which  two  occurred 
in  the  week  preceding  my  visit.  On  the  occasion  of  the  first  of 
these  he  felt  dizziness,  and  was  obliged  to  lay  hold  of  his  desk. 
He  thought  he  was  going  to  fall,  and  shortly  afterwards  he  did 
fall,  unconscious.    He  is  not  aware  of  having  bitten  his  tongue. 

Present  state. — The  sight  of  the  right  eye  is  almost  nil,  on 
account  of  a  large  leukoma  of  the  cornea,  concealing  nearly  the 
entire  pupil.  The  squint,  which  is  said  to  be  of  old  standing, 
is  not  accompanied  by  double  vision.  He  walks  feebly  and 
with  a  tottering  gait.  There  is  no  power  of  grasping  with 
either  hand.  This  failure  of  strength,  he  says,  has  only  taken 
place  during  the  last  four  days,  but  for  the  last  week  he  has 
been  feeling  increasingly  feeble.  There  is  no  marked  want  of 
symmetry  in  the  face.  His  tongue  is  protruded  straight.  The 
patient  cries  out  every  now  and  then  with  aching  pains  in  the 
arms,  sometimes  in  one  and  sometimes  in  the  other.  Fre- 
quently there  is  much  pain  over  the  brows  and  across  the 
back.  At  times,  he  says,  he  suffers  from  pain  all  round  the 
lower  part  of  the  head  behind. 

For  some  months  past  he  has  been  liable  to  what  he  calls 
"  rheumatism  "  in  his  limbs,  and  aching  pains  across  the  head 


ON   SOME   VARIETIES   OF   CERVICAL    PARAPLEGIA.       59 

and  loins.  There  is  what  he  describes  as  "  painful  numbness  " 
in  both  arms. 

The  heart  and  lungs  are  healthy.    Appetite  and  digestion  bad. 

By  the  ophthalmoscope  (under  great  difficulty,  owing  to 
unsteadiness,  very  small  pupil,  and  some  considerable  haziness 
of  the  media)  the  retinal  vessels  in  the  left  eye  appeared  tortuous, 
and  the  outline  of  the  disc  indistinct.  The  large  opacity 
precluded  observation  of  the  right  fundus  oculi. 

His  landlady  told  me  that  six  or  seven  weeks  before  this  his 
manner  had  appeared  very  strange,  and  his  memory  had  failed 
him  to  a  large  extent.  It  seemed  that  for  a  week  past  he  had 
been  taking  small  doses  of  bromide.  I  ordered  perchloride  of 
mercury  and  iodide  of  potassium. 

A  week  later  he  came  to  my  house,  distinctly  improved  in 
intelligence.  I  noted  that  he  held  his  head  as  though  he 
had  a  stiff  neck,  and  complained  of  pains  at  the  back  of  the 
head  and  across  the  right  ear. 

There  was  a  peculiarly  helpless  look  about  his  hands.  The 
excitability  of  the  muscles  of  his  arms  was  diminished  in  a 
marked  degree  to  the  faradic  current. 

Whilst  examining  him  with  the  ophthalmoscope,  I  noticed 
that  he  was  constantly  swaying  about,  and  frequently  exclaim- 
ing suddenly  as  from  the  effects  of  pain.  His  arms  would 
jerk,  and  he  complained  of  sharp  pains  in  them. 

His  temperature  was  normal.  The  urine  contained  no  albu- 
men or  sugar. 

After  another  fortnight's  treatment  with  mercury  and  iodide, 
he  was  manifestly  much  improved.  There  had  been  no  repetition 
of  a  fit.  He  had  lost  the.  pains  in  his  arms,  and  there  was  but 
little  pain  in  the  head.  The  right  leg  was  stronger.  He  de- 
scribed a  feeling  of  tightness  around  the  waist,  which  he  had 
experienced  for  two  or  three  days,  but  which  was  relieved  by 
the  action  of  the  bowels.  The  mind  appeared  to  be  quite 
clear.  By  the  ophthalmoscope  the  left  disc  appeared  to  be 
more  distinctly  defined,  but  the  vessels  remained  tortuous.  He 
was  ordered  one-sixteenth  of  a  grain  of  perchloride  of  mercury 
with  twenty  grains  of  iodide  of  potassium  three  times  a  day, 
and  twenty  grains  of  bromide  of  potassium  at  bedtime. 


60       ON   SOME   VARIETIES   OF   CERVICAL    PARAPLEGIA. 

On  August  3rd  the  following  note  was  made  :  "  Three  days 
ago  he  had  a  repetition  of  a  feeling  which  he  had  not  expe- 
rienced for  a  year  previously,  and  which  then  ushered  in  a  fit. 
The  feeling  was  of  a  whirling  round  in  the  centre  of  his  head. 
He  had  a  trifling  amount  of  pain  at  the  back  of  the  head. 

"  His  walking  power  improves  daily.  He  walked  to-day  the 
best  part  of  a  mile,  although  there  is  still  weakness,  especially 
in  the  right  leg. 

"  There  is  wasting  of  the  dorsal  interossei  in  each  hand,  but 
the  fingers  have  regained  warmth  and  colour  (they  had  been 
cold  and  dead-looking).  Their  movements  are,  however,  still 
very  clumsy.  This  morning  he  lifted  the  ewer,  which  he  could 
not  have  done  three  clays  ago. 

"The  electrical  reaction  in  the  muscles  of  the  forearm  is 
somewhat  improved." 

The  following  note  of  diagnosis  was  also  made  at  this  time  : 
"  One  would  think,  from  the  powerlessness  and  wasting  of  the 
muscles,  together  with  loss  of  electric  irritability,  that  here  was 
a  case  of  pressure  upon  the  anterior  roots  of  nerves,  probably 
from  pachymeningitis." 

Three  weeks  later  the  patient  had  gained  strength  ;  and 
was  able  to  walk  as  much  as  three  miles.  The  arms,  too, 
had  greatly  improved.  He  had  resumed  his  usual  hand- 
writing with  a  pencil,  but  there  was  too  much  clumsiness 
in  the  fingers  for  the  successful  use  of  a  pen ;  nor  could  he 
pick  up  coins  or  pins.  "  It  was  only  the  fingers,"  he  said, 
"  which  were  still  obstinate  and  had  not  regained  their 
pliancy."  The  hands  felt  generally  warm  in  the  evening. 
The  warmth  of  the  bed  seemed  to  soothe  them.  Contact  with 
metal  appeared  to  send  them  "  all  ajar."  There  was  no  pain 
in  the  head :  his  appetite  was  good  and  he  slept  well.  He  had 
been  taking  the  iodide  with  a  little  iron. 

On  September  1 2  it  is  noted  that  the  patient  can  walk  three 
to  four  miles  without  fatigue.  The  grasp  of  the  left  hand  is 
very  imperfect,  and  there  is  still  wasting  of  the  interossei,  as  well 
as  an  "  electrical  sensation  "  in  that  hand.  His  gait  is  rather 
jerky  and  disorderly.  He  is  somewhat  restless  at  night.  There 
is  a  sense  of  fulness,  but  no  pain,  at  the  back  of  the  head.  A  few 
days  after  this  he  began  to  get  more  pain  in  the  right  arm, 


ON   SOME   VARIETIES  OF   CERVICAL   PARAPLEGIA.      61 

especially  from  the  middle  of  the  upper  arm  down  to  the  tip 
of  the  ring-finger.  On  examination,  the  ring  and  little  fingers 
of  the  right  hand  were  found  to  be  clumsy,  and  unnatural  in 
their  movements. 

September  20th. — There  has  only  been  a  little  pain,  "  almost 
what  he  might  describe  as. a  sympathetic  feeling,"  in  the  left 
arm.  But  the  fingers  of  the  left  hand  are  much  more  helpless 
and  clumsy  than  those  of  the  right. 

"  At  this  moment "  (I  note)  "  there  is  no  pain  in  the  right 
arm,  but  he  has  had  several  paroxysms  this  morning  and  many 
in  the  night.  The  pain  is  almost  unbearable.  It  comes  on 
very  suddenly —  a  burning  aching  pain,  '  as  if  the  vein  were 
filled  with  molten  lead.'  The  day  before  yesterday  the  pain 
was  so  intense  that  he  '  started  up,  and  broke  into  a  perspira- 
tion all  over.'  A  paroxysm  will  last  about  half  a  minute.  It 
seems  to  begin  at  the  top  of  the  arm,  and  it  '  must  go  its 
course.'  After  the  pain  has  left,  a  feeling  of  relief  alone 
remains.  He  can  lift  his  arm  during  the  pain ;  in  fact  the 
exertion  of  the  muscles  seems  to  give  relief.  It  is  usually  when 
the  pain  is  going  on  in  the  right  arm  that  he  gets  a  little  pain 
in  the  left.  But  he  thinks  (questioned)  that  he  has  sometimes 
a  little  pain  in  the  left  arm  when  none  is  going  on  in  the  right." 

Examination  showed  that  the  excitability  of  the  muscles  of 
both  arms  to  induced  currents  was  much  diminished,  but  not 
removed.  There  was  still  wasting  of  the  interossei,  but  not,  it 
was  thought,  so  great  as  had  been.  He  was  unsteady  on  his 
legs,  especially  on  the  left. 

A  week  ago  he  felt  pretty  well,  and  went  by  rail  to  the 
Crystal  Palace.  He  undressed  in  my  room  for  examination, 
and  appeared  to  be  very  helpless ;  I  had  to  button  his  clothes. 
By  the  ophthalmoscope,  I  found  the  retinal  vessels  of  the  left 
fundus  very  tortuous,  but  the  outline  of  the  disc  distinct 
enough.  I  dilated  the  right  pupil  with  atropine,  but  the 
opacity  prevented  any  observation  of  the  fundus.  Three  days 
ago  he  went  and  dined  with  a  friend  in  the  City  (a  distance  of 
some  six  or  seven  miles).     The  following  day  was  spent  indoors. 

The  patient  was  now  placed  under  the  care  of  Mr.  Harrison, 
of  Streatham,  whom  I  met  in  consultation  on  November  1. 


62       ON   SOME   VARIETIES   OF   CERVICAL   PARAPLEGIA. 

S was  up  and  dressed,  seated  in  a  chair.     The  arms  were 

much  atrophied,  and  the  legs  also,  but  to  a  less  extent.  He  did 
not  complain  of  pain  in  the  arms,  but  occasionally  I  observed 
them  to  be  jerked,  and  then  he  would  cry  out.  When  asked 
to  explain  the  cause,  he  said  that  he  had  the  cramp  in  them. 

The  left  forearm  showed  hyperesthesia  to  cold,  but  there 
was  delay  in  receiving  the  impression  of  pinches. 

There  was  paralysis  of  the  sphincters,  with  ammoniacal  urine. 

The  patient  was  put  on  a  water-bed  and  ordered  one-sixteenth 
of  a  grain  of  perchloride  of  mercury  with  fifteen  grains  of  iodide 
of  potassium  three  times  daily ;  also  some  lactophosphate  of  iron. 

November  17th. — I  heard  that  there  was  complete  paralysis 
of  the  intercostal  muscles,  and  the  breathing  was  entirely 
diaphragmatic.  The  patient  was  having  epileptiform  attacks 
every  day.     He  was  thought  to  be  dying. 

November  20th. — As  the  gums  were  beginning  to  be  sore, 
the  mercury  was  stopped  and  the  iodide  continued. 

December  10th. — Mr.  Harrison  wrote  that  there  had  been  a 
slight  improvement.  The  intercostal  muscles  were  acting 
slightly,  and  there  was  more  power  in  the  arms  and  legs. 

About  a  week  before  his  death,  which  took  place  on  Decem- 
ber 24th,  he  was  removed  into  other  lodgings.  At  this  time  he 
could  just  slowly  and  tremulously  lift  a  handkerchief  and  give 
a  very  slight  squeeze  with  either  hand.  The  arms  appeared  to 
be  equally  weak. 

For  many  weeks  before  the  end  he  could  not  stand,  and  was 
indeed  unable  to  lift  his  foot  from  the  floor ;  but  during  the 
last  few  days  of  his  life  he  could  do  this.  Towards  the  close 
he  became  exceedingly  irritable  in  temper. 

On  December  23rd,  he  was  taken  with  insensibility  and 
stertorous  breathing,  and  died  the  following  day,  having 
never  recovered  consciousness. 

The  autopsy  took  place  52  hours  after  death,  in  the  presence 
of  Mr.  Harrison  and  myself.  Weather  very  cold.  The  body 
was  extremely  exsanguineous ;  a  small  bedsore  on  the  sacrum. 
Much  wasting  of  muscles  was  noted  in  the  forearms  and  hands, 
not  so  much  in  the  upper  arms.  The  legs  were  thin,  but  did 
not  appear  so  much  atrophied  as  the  upper  extremities. 


ON   SOME   VARIETIES  OF   CERVICAL   PARAPLEGIA.      63 

Head. — There  was  some  slight  opacity  of  the  arachnoid 
membrane.  The  brain-substance  generally  was  soft,  putty- 
like in  consistence,  wanting  in  firmness.  The  left  crus  cerebri 
was  almost  in  a  fluid  state  of  softening.  The  surface  of  the 
pons  varolii,  and  also  of  the  medulla  oblongata,  was  softened. 
The  basilar  artery  was  thickened,  and  contained  a  thrombus. 
There  was  a  large  quantity  of  fluid  in  the  ventricles. 

Spinal  Cord;  anterior  aspect. — On  ripping  open  the  dura- 
mater  from  below  upwards  no  change  is  noticeable  until  the 
upper  dorsal  region  is  reached,  when  this  membrane  is 
found  glued  together  with  the  soft  membranes,  and  the  whole 
mass  firmly  adherent  to  the  cord.  With  the  finger  one  feels 
a  hardness  about  the  size  of  a  bean  at  the  left  side  of  the  cord 
at  the  lower  point  of  the  cervical  enlargement.  Here  it  is 
found  that  for  about  12  millimetres  there  is  complete  adhesion  to- 
gether of  both  hard  and  soft  membranes :  thence  upwards  for 
nearly  4  centimetres  the  pia  mater  is  much  thickened  and 
adherent  to  the  cord.  At  this  part  the  cord,  on  section,  is 
found  to  be  of  the  consistence  of  rotten  cheese.  The  whole 
extent  of  this  softening  is  about  two  inches  longitudinally. 
Above  this  again,  and  for  the  remaining  12  millimetres  or 
so  of  the  separated  cord,  the  substance  feels  firmer,  if  not  of 
natural  solidity. 

Posterior  aspect. — The  membranes  appear  natural,  until  we 
come  to  about  16  centimetres  above  the  pointed  extremity  of  the 
cord,  where  the  dura  mater  is  found  thickened  and  adherent 
to  the  soft  membranes.  Slitting  these  up,  they  can  with  some 
little  force  be  separated  from  the  surface  of  the  cord,  and  then 
this  latter,  as  well  as  the  exposed  surface  of  soft  membrane,  wears 
an  aspect  of  erosion,  and  is  pink  in  colour.  It  is  evident  that 
one  is  tearing  through  recent  inflammatory  adhesion.  This 
adhesion  is  very  close  for  about  4  centimetres,  and  thence 
upwards,  continues,  though  not  so  firmly,  till  we  come  to 
the  cervical  enlargement,  where  there  is  (as  on  the  anterior 
aspect)  a  matting  together  of  all  the  membranes.  On  cutting 
through  the  part  where  the  hardness  previously  described  is 
most  pronounced,  we  find  that  it  is  of  almost  cartilaginous 
quality  in  section,  and  measures  *5  cm.  in  thickness.  The 
cord  is  nearly  fluid  at  this  point,  and  scarcely  a  trace  of  the 
pattern  of  grey  matter  is  to  be  seen  on  section. 


64      ON   SOME   VARIETIES   OP  CERVICAL   PARAPLEGIA. 

There  was  no  disease  of  the  vertebrae. 

My  friend  Dr.  H.  R.  0.  Sankey,  of  the  County  Asylum, 
Prestwich,  was  kind  enough  to  examine  the  cord  for  me,  and 
his  report  is  as  follows  : — 

"  Transverse  sections  of  the  piece  of  cord  which  was  sent  to 
me  were  very  difficult  to  cut,  owing  to  the  friability  of  the 
cord  substance  and  the  toughness  of  the  thickened  pia  mater. 

"  Microscopical  appearance  of  Pia  Mater.— At  the  posterior 
part  of  the  cord  this  was  thicker  than  at  the  anterior,  and 
where  it  was  thickest  it  measured  about  ^  inch.  It  consisted 
of  connective  tissue,  but  was  not  at  all  uniform  in  structure. 
At  some  places  it  was  highly  cellular ;  at  others  chiefly  fibrous. 
The  arrangement  was  very  irregular,  but  at  one  part  an  ap- 
pearance was  seen  in  which  the  fibrous  bundles  were  very 
regular  in  arrangement  and  parallel  to  the  cord.  But  few 
vessels  exist  in  this  structure ;  those  observed,  however,  were 
well  developed,  especially  as  to  the  adventitia,  which  passed 
insensibly  into  the  general  fibrous  matrix  in  which  they  lay. 
In  one  case  a  very  thin-walled  lacuna-like  space  was  seen 
filled  with  blood,  which  was  uniformly  coagulated,  and  had  not 
long  been  in  this  position. 

"The  band  of  connective  tissue  which  passes  into  the  an- 
terior fissure  is  greatly  thickened,  and  contains  vessels  which 
are  altered  in  the  same  manner  as  those  of  the  substance  of  the 
cord  (vide  infra).  The  adhesion  between  the  pia  mater  and 
the  cord  substance  was  broken  down  in  the  cutting  of  the 
sections,  and  cannot  be  made  out,  but  it  is  probable  that  the 
entering  trabecule  are  not  thickened,  but  rather  softened,  like 
the  cord  substance. 

"  White  Matter  of  the  Cord. — This  is  throughout  greatly 
altered.     The  changes  are  as  follows  : — 

"  1.  Ascending  fibres  are  in  many  parts  only  represented  by 
homogeneous  globules,  staining  slightly  in  carmine  and  log- 
wood; while  in  others  a  few  more  or  less  normal  fibres  are  seen; 
and  in  others  only  the  shrivelled  sheath  of  Schwann  can  be 
seen,  devoid  of  axis  cylinder,  and  filled  with  a  homogeneous 
drop  of  myelin. 

"  2.  Connective  tissue  is  greatly  increased.  As  to  its 
cellular  constituents,  immense  quantities  of  new  cells,  darkly 
stained,  cover  the  field  of  view  at  every  part. 


i 


ON   SOME   VARIETIES   OF   CERVICAL    PARAPLEGIA.      65 

"  3.  A  granular  debris  fills  the  spaces  left  by  these  two 
elements.  (N.B.  Some  of  these  appearances  may  be  due  to 
post-mortem  decomposition,  i.e.  the  state  of  the  more  healthy 
nerve  tubercles  and  the  granular  appearance  just  described; 
the  cells  cannot  be.) 

"  Vessels  are  large,  tortuous,  and  the  walls  are  covered  by 
new  cells,  so  that  their  structure  is  in  places  quite  obscured. 
In  some  places,  where  it  can  be  seen,  it  is  healthy,  and  the 
vessels  are  all  void  of  blood,  or  nearly  so,  and  patent. 

"  Grey  Matter. — Of  the  two  cornua  (anterior)  the  left  is  the 
more  diseased.  In  this  one,  two  or  three  nerve  cells  can  be  seen. 
These  are  circular  bodies,  shorn  of  all  processes,  showing  a 
granular  nucleus  evidently  in  the  last  stage  of  degeneration. 
In  the  right  cornua  a  larger  number  of  cells  are  seen.  They 
are  more  refractive  than  usual.  They  are  in  many  instances 
devoid  of  processes,  but  retain  them  in  other  cases  for  a  short 
distance.  The  posterior  cornua  are  involved  in  the  disorganisa- 
tion. It  is,  however,  impossible  to  say  that  they  have  suffered 
more  than  other  parts,  or  that  the  right  has  suffered  more  than 
the  left. 

"  All  that  can  be  made  of  the  rest  of  the  grey  matter  is  that 
it  contains  too  many  nuclei,  and  is  granular  and  opaque,  and 
contains  vessels  surrounded  by  cells  to  a  great  extent.  Ono 
vessel  near  the  central  canal  contains  an  ante-mortem  clot. 

"  Summary. — 1.  .Fibrous  thickening  of  pia  mater. 

"  2.  Infiltration  of  cord  by  new  cells  from  vessels,  and  in- 
crease of  existing  connective  tissue  by  migration  or  otherwise. 

"  3.  Destruction  of  normal  constituents. 

"  4.  Post-mortem  decomposition." 

I  take  this  to  have  been  a  case  of  inflammation  of  the 
internal  layer  of  the  spinal  dura  mater,  of  the  arachnoid,  and 
pia  mater,  the  hard  and  soft  membranes  being  agglutinated  at 
the  point  described  into  a  mass  which  was  strongly  adherent 
to  the  cord.  The  external  layer  of  dura  mater  appeared  to 
be  unaltered.  Dr.  Sankey  speaks  of  the  tough  mass  as 
thickened  "  pia  mater,"  but  I  imagine  it  is  difficult  to  say 
with  which  of  the  membranes  the  hypertrophy  described  is  to 
be  especially  associated,  for  they  are  all  involved. 

VOL.    III.  F 


66       ON   SOME   VARIETIES   OF   CERVICAL   PARAPLEGIA. 

Charcot,1  writing  of  hypertrophic  cervical  pachymeningitis, 
remarks  that  it  consists  of  an  alteration  of  membranes  affecting 
more  especially  the  dura  mater,  and  notes  that  the  cervical  en- 
largement of  the  cord  is  in  some  respects  a  favourite  seat  of  it. 
The  alteration  in  the  dura  mater  is  the  primary  fact,  but  later 
on  the  cord  and  the  peripheral  nerves  are  involved.  He  thinks 
that  the  cases  formerly  described  by  Laennec,  Andral,  and 
Hutin,  under  the  name  of  "  hypertrophy  of  the  spinal  cord," 
properly  belonged  to  cervical  pachymeningitis ;  the  swelling, 
which  was  really  due  to  the  membranes,  being  attributed  to 
the  cord  itself.  As  a  matter  of  fact,  the  cord,  far  from  being 
hypertrophied,  is  squeezed  from  before  backwards.  The  pia 
mater  is  affected,  but  much  less  than  the  dura  mater,  which 
may  attain  a  thickness,  he  remarks,  of  6  or  7  mm.  (In  the 
case  above  described  the  thickness,  when  the  cord  was  fresh, 
was  5  mm.)  The  dura  mater  is  usually  altered  in  its  entire 
thickness,  as  is  proved  by  the  adhesions  which  unite  it  outside 
to  the  vertebral  ligament,  inside  to  the  pia  mater.  In  the 
present  case  it  will  have  been  observed  that  the  external  layer 
of  dura  mater  was  free  from  change. 

With  this  remarkable  thickening  and  agglutination  of  mem- 
branes the  cord  at  the  part  most  affected  by  meningitis  was 
broken  down  and  disorganised.  The  condition  was  one  of 
meningo-myelitis,  which  I  should  think  was  probably  syphi- 
litic in  origin,  for  the  following  reasons  : — 1.  The  patient  had 
suffered  some  eight  or  nine  years  previously  from  a  venereal 
ulcer.  2.  The  autopsy  showed  the  basilar  artery  thickened, 
and  thrombosed  ;  the  crus  cerebri,  pons  varolii,  and  medulla 
oblongata  softened.  The  patient's  age  was  about  35 — too  early 
for  the  arterial  change  to  be  reasonably  ascribed  to  senile  de- 
generation. The  thickening  (endarteritis)  was  precisely  of  the 
character  which  we  see  so  frequently  in  the  cerebral  arteries 
in  the  sequel  of  syphilis.  3.  During  life,  as  will  have  been 
observed,  an  extraordinary  improvement  took  place  in  the 
patient  very  shortly  after  he  began  to  receive  specific  treat- 
ment, especially  as  regards  his  lower  extremities. 

In  view  of  the  state  of  the  cornea  in  each  eye,  and  the 
history  of   fits  in  childhood,  it  seems   quite    probable   that 

1  '  Lemons  sur  lea  Maladies  flu  Systemo  Nervcux.' 


ON   SOME    VAEIETIES   OF   CERVICAL    PARAPLEGIA.      67 

the   patient   may  also  have  been   the   subject  of  congenital 
syphilis. 

I  was  anxious  to  discover  whether  in  this  case  a  micro- 
scopical examination  would  disclose  thickening  of  the  walls  of 
the  vessels  in  the  substance  of  the  cord.  It  appears  to  be  very 
likely  that  in  cases  of  syphilis  there  is  frequently  such  a 
thickening  of  the  walls  of  the  spinal  arteries  as  experience 
has  proved  to  be  the  case  as  regards  the  intracranial  arteries. 
Such  a  thickening  was  found  in  the  basilar  artery  in  the  pre- 
sent instance,  and  it  appeared,  therefore,  at  the  least  probable 
that  a  similar  condition  might  have  existed  in  the  vertebral 
arteries  or  their  branches.  I  regret  that  it  did  not  occur  to 
me  at  the  autopsy  (which  was  made  under  circumstances  of 
some  difficulty)  to  remove  specimens  of  the  vertebral  arteries 
for  examination.  The  hardening  of  the  cord  was  not  accom- 
plished very  satisfactorily,  and  Dr.  Sankey  had  some  trouble 
in  his  examination.  He  found  that  the  vessels,  as  well  in  the 
substance  of  the  cord  as  in  the  connective  tissue  dipping  into 
the  anterior  fissure,  were  large,  tortuous,  and  their  walls  covered 
by  new  cells,  but  in  only  one  instance  was  he  able  to  observe  the 
presence  of  an  ante-mortem  clot.  This,  however,  isolated  as  it  is, 
is  of  great  importance.  We  are  still  unable  to  say  anything 
certain  regarding  the  stage  at  which  this  thrombosis  of  a  thick- 
ened vessel  occurred,  or  as  to  the  relation  in  point  of  time  between 
the  inflammation  of  the  membranes  and  the  myelitis.  Nor  does 
the  clinical  history  aid  us  in  any  attempt  at  deciding  whether 
the  cord  or  its  membranes  was  first  attacked  with  inflammation. 

The  paralysis  of  the  arms  in  this  man  was  throughout  much 
more  marked  than  that  of  the  lower  extremities.  This  was 
doubtless  because  in  the  former  case  it  was  due  in  great  part 
to  disorganisation  of  the  centres  within  the  cord,  in  the  latter 
partly  to  the  result  of  meningitis,  partly  also  to  the  interrup- 
tion of  nervous  impulses  caused  by  the  slow  compression  in 
the  cervical  region.  The  appearances  would  lead  to  the 
inference  that  under  the  specific  treatment  the  recent  in- 
flammation of  the  membranes  in  the  dorsal  and  lumbar 
regions  had  very  much  cleared  up.  The  treatment  came  too 
late  to  affect  to  the  same  extent  the  more  or  less  organised 
thickening  of  the  membranes  in  the  cervical  region,  although  it 

p  2 


68       ON   SOME   VARIETIES   OF   CERVICAL   PARAPLEGIA. 

is  surprising  to  note  the  amount  of  improvement  which  did 
take  place  in  the  state  of  the  arms.  I  do  not  feel  able  to 
explain  satisfactorily  the  reason  of  this. 

The  pains,  as  they  were  described  by  this  patient,  were 
characteristic  of  a  membranous  lesion,  causing  irritation,  espe- 
cially of  the  posterior  roots  of  the  brachial  plexus.  As  Charcot 
has  pointed  out,  these  pains  may  be  met  with  in  intra-rachi- 
dian  tumours,  in  Pott's  disease,  and  in  vertebral  cancer,  as  well 
as  in  hypertrophic  cervical  pachymeningitis. 

The  contraction  of  the  pupils  which  existed  here  is  well 
known  as  an  accompaniment  of  lesions  of  the  upper  part  of 
the  spinal  cord. 

According  to  Charcot,  epileptic  attacks  sometimes  manifest 
themselves  periodically  in  cases  of  compression-lesion  of  the 
cord.  Although  this  association  is  comparatively  rare,  he  has 
been  able  to  collect  five  cases  of  this  kind.  In  the  present 
case  I  believe  that  there  was  optic  neuritis,  although  I  am  un- 
able to  speak  so  positively  on  this  point  as  would  have  been 
desirable.  The  difficulty  of  using  the  ophthalmoscope  was  very 
great  even  when  the  pupil  was  dilated,  as  the  patient  presented 
ataxic  movements,  swaying  to  and  fro  on  the  chair,  and  jerking 
his  arms  occasionally,  as  he  was  seized  with  a  dart  of  pain ; 
and  on  account  of  the  haziness  of  the  media.  I  could  find 
no  trace  of  gumma  in  the  membranes  of  the  brain,  but 
it  is  always  possible  that  a  formation  of  this  kind  may  have 
been  absorbed  under  treatment.  In  view  of  the  probable 
existence  of  optic  neuritis  and  the  certain  thrombosis  of  the 
basilar  artery  and  the  cerebral  softening,  I  do  not  think  we 
can  reasonably  refer  the  epileptic  seizures  in  this  case  to  the 
compression  of  the  cord  in  the  cervical  region. 

Case  II. — Stiffness  and  aching  of  the  right  arm,  followed,  after 
three  months,  by  loss  of  power  in  the  left  arm  and  leg  ;  atrophy 
of  interossei  in  the  left  hand  ;  impaired  cutaneous  sensibility  of 
right  arm  ;  tenderness  on  pressing  4th  cervical  spine  ;  return  of 
power  in  left  limb,  with  more  or  less  spastic  rigidity  and  exag- 
gerated reflex  ;  family  history  of  phthisis. 

A  lady,  set.  26,  married  two  years,  never  pregnant,  was  sent 


ON   SOME   VARIETIES  OF   CERVICAL   PARAPLEGIA.      69 

to  me  in  July  1879,  on  account  of  weakness  and  numbness 
in  her  limbs.  She  complained  that  her  right  arm  was  stiff 
and  ached,  the  hand  being  numbed  and  tingling  as  though 
it  had  "  gone  to  sleep."  This  had  been  the  case  since  March 
last.  Her  attention  had  first  been  attracted  by  a  change 
in  her  handwriting.  There*  was  nothing  the  matter  with 
the  right  leg.  About  a  week  before  I  saw  her,  the  left  arm, 
which  had  been  previously  unaffected,  had  lost  power,  and 
continued  feeble,  without  any  such  tingling  or  numbness 
as  was  experienced  on  the  right  side.  At  the  same  time,  with 
this  accession  of  weakness  in  the  left  arm,  she  found  herself 
swerving  to  the  left  from  weakness  of  the  left  leg.  The  left 
leg,  like  the  arm,  continued  weak.  If  she  held  anything 
heavy  in  her  left  hand  it  trembled.  The  aspect  of  the  limbs 
was  unaltered,  and  there  was  no  apparent  wasting. 

In  the  arms  the  reaction  of  the  muscles  to  faradism  was 
normal.  In  the  lower  extremities  there  appeared  to  be  some 
diminution  of  excitability  in  the  tibialis  anticus  group  of  each 
leg,  but  this  was  doubtful,  as  it  was  equal  on  the  two  sides. 
The  electric  current  was  felt  much  more  strongly  in  the  right 
than  the  left  leg. 

The  patient  complained  of  the  lower  part  of  her  back  aching 
in  the  morning  on  waking.  She  had  never  suffered  from  bad 
pain  in  the  head,  but  at  times  had  been  troubled  with  a  little 
neuralgia.  She  was  thin  and  strumous-looking.  On  her 
father's  side  there  is  much  consumption,  six  aunts  and  one 
uncle  (paternal)  having  died  of  phthisis  before  thirty  years 
of  age.  There  is  no  history  of  injury.  The  catamenia  are 
regular. 

A  month  after  her  visit  to  me,  on  getting  out  of  bed  one 
morning  she  fell  down,  owing  to  a  rather  sudden  increase  of 
weakness  in  the  left  limbs.  I  saw  her  a  day  or  two  afterwards, 
when  the  left  arm  was  very  powerless,  especially  about  the 
scapulo-humeral  muscles.  In  walking  she  swerved  always  to 
the  left.  There  was  a  difference  in  the  sensibility  of  the  two 
arms,  a  touch  being  felt  more  on  the  left  than  the  right — the 
sensibility  of  the  right  being  evidently  dulled.  If  she  at- 
tempted to  hold  a  book  in  the  left  hand,  it  slipped  through 
her  fingers. 


70       ON   SOME   VARIETIES  OF   CERVICAL    PARAPLEGIA. 

I  found  that  deep  pressure  on  the  spine  caused  pain  over 
the  fourth  cervical  vertebra.  In  no  other  part  of  the  spine  was 
tenderness  complained  of  when  pressure  was  applied,  and 
repeated  examination  always  caused  it  at  this  point. 

The  recumbent  posture  and  general  attention  to  nutrition 
by  food  and  drugs  was  -the  treatment  adopted. 

In  October  last  her  condition  was  noted  as  follows  : — 

The  right  arm  is  somewhat  stiff,  and  there  is  want  of 
perceptive  power  by  the  fingers  and  thumb.  The  grasp  of 
this  hand  is  appreciable,  but  weak. 

In  the  left  hand  there  is  some  slight  power  of  grasp,  though 
less  than  in  the  right,  and  no  apparent  affection  of  sensibility. 
In  using  the  arm,  as  in  attempting  to  hold  a  fork,  there  is 
trembling  of  the  limb.  There  is  some  atrophy  of  the  dorsal 
interossei  in  the  left  hand  with  over-extension  of  the  first 
phalanges,  and  some  atrophy  also  of  the  thenar  eminence. 
The  over-extension  of  the  first  phalanges  causes  the  meta- 
carpo-phalangeal  joints  to  project  in  the  palm  of  the  hand. 
The  patient  can  touch  the  back  of  the  head  with  the  left 
hand,  the  movement  being  accompanied  by  tremor,  and 
causing  some  aching  in  the  arm.  The  right  leg  has  continued 
to  be  unaffected.  The  left  leg  is  still  weak.  In  walking,  this 
leg  is  stiff,  and  the  foot  is  carried  in  a  semicircle.  She  tends 
to  walk  on  the  inside  of  the  foot.  There  is  difficulty  in  dorsal 
flexion,  the  foot  trembling  when  she  attempts  it.  There  is 
some  increase  of  patellar  tendon  reflex  in  this  leg.  The 
general  health  is  good. 

I  have  to-day  (March  5th,  1880)  received  an  account  of  her 
present  condition.  The  left  hand,  it  is  said,  can  be  used 
perfectly  well  for  all  practical  purposes,  although  it  feels 
rather  weak  and  inclined  to  tremble.  The  middle  finger  is 
still  en  griffe,  but  she  thinks  there  has  always  been  a  tendency 
to  that  position.  During  the  past  winter  she  has  suffered 
much  from  chilblains,  and  the  fingers  have  not  yet  recovered 
their  proper  shape.  The  muscles  of  the  arm  ache  if  she 
extends  it  from  the  shoulder,  and  if  she  attempts  to  do  her 
hair. 

There  is  still  a  little  lameness  in  walking,  and  the  sole  of 
the  left  foot  has  a  tendency  to  scrape  the  ground. 


ON  SOME   VARIETIES   OF   CERVICAL   PARAPLEGIA.      71 

At  no  time  has  there  been  any  affection  of  the  bladder  or 
rectum. 

In  this  case  we  may  at  least  localise  the  lesion  in  the 
cervical  region.  The  circumstance  of  the  left  leg  as  well  as 
the  arm  being  affected  would'  imply  that  it  is  the  substance  of 
the  cord  (and  not  merely  the  membranes)  in  this  region  which 
is  in  some  way  involved.  An  affection  of  the  anterior  roots  of 
spinal  nerves  alone  might  explain  the  powerlessness,  and  also 
the  muscular  atrophy  in  the  left  hand,  but  the  affection  of  the 
left  leg,  and,  still  more,  the  rigidity  in  these  limbs,  pointing 
to  secondary  degeneration  in  the  lateral  column,  appears  to 
show  that  we  must  seek  the  cause  of  the  paralysis  and  atrophy 
in  lesion  of  the  anterior  cornua  in  the  cervical  region.  The 
lesion  is  one  which  apparently  affects  especially  the  left  side 
of  the  cord.  There  may  be  a  tumour,  or,  what  would  be  more 
probable,  considering  the  family  history,  and  the  pain  expe- 
rienced when  the  fourth  cervical  spine  is  pressed,  some  verte- 
bral caries  with  pachymeningitis,  causing  compression  and 
some  resulting  myelitis. 

In  the  case  which  follows,  and  which  in  certain  respects 
presents  several  points  of  resemblance  to  the  one  just  related, 
the  conditions  observed  are  consequent  on  an  accident.  The 
lad  appears  indeed  to  have  "  broken  his  neck." 

Case  III. — Injury  to  cervical  spine  whilst  diving;  complete 
paraplegia  of  all  four  limbs  ;  recovery  of  power,  with  spastic 
condition  of  limbs  from  secondary  degeneration. 

George  H.,  aet.  18,  by  occupation  a  gardener,  whilst  bathing 
on  July  18th,  1878,  dived  and  struck  his  head  against  the 
bottom  of  the  river  in  six  feet  of  water.  He  was  unconscious 
for  a  few  minutes,  and  on  coming  to  himself  felt  great  pain  in 
the  back  of  the  neck  (level  of  third  and  fourth  cervical 
spines),  and  found  that  there  was  total  loss  of  power  in  all 
four  limbs.  Both  hands  were  clenched  after  the  accident,  he 
says,  and  for  a  week  he  could  not  open  them,  nor  could  he 
move  his  head  "  any  way."  He  says  that  he  could  feel  "  wheu 
they  washed  him." 


72       ON   SOME   VARIETIES   OF   CERVICAL   PARAPLEGIA. 

About  a  week  from  the  time  of  the  accident  he  began  to 
recover  power  gradually,  in  the  right  leg  and  arm  first. 

In  January  1879  he  could  just  manage  to  stand  with  a 
chair ;  in  March  he  could  walk  a  few  yards  by  himself ;  and 
in  April  could  dress  himself.  Since  May  he  has  been  able  to 
walk  by  himself  with  the  aid  of  a  stick. 

When  he  applied  at  the  National  Hospital  for  the  Paralysed 
and  Epileptic  as  an  out-patient,  on  July  9th,  1879,  I  noted 
that  the  electrical  reaction  of  the  left  deltoid  muscle  was  greater 
than  that  of  the  right  to  faradism,  and  less  to  the  inter- 
rupted Voltaic  current.  The  electrical  reaction  of  the  muscles 
of  the  legs  appeared  to  be  normal. 

The  patient  was  admitted  into  the  hospital  in  October  last, 
when  the  following  note  of  his  state  was  taken  by  Mr.  A.  E. 
Broster,  Resident  Medical  Officer : — 

"  The  spinal  column  shows  nothing  abnormal. 

"  The  head  can  be  moved  perfectly  in  all  directions.  His 
breathing  is  natural,  the  diaphragm  acting  normally. 

"  Upper  limls. — There  is  no  muscular  wasting.  The  grasp  of 
the  right  hand  is  35  dynamometer,  of  the  left  20.  There  is 
some  rigidity  about  the  wrists,  especially  the  left,  and  the  hands 
have  a  tendency  to  drop.  During  the  movements  of  the  arms 
there  is  some  shaking.     The  muscular  sense  is  normal. 

"  Lower  limls. — The  legs  present  some  '  clasp-knife  '  rigidity ; 
the  thighs  resist  abduction.  His  walk  is  stiff  and  slow,  the 
left  foot  apparently  dragging  more  than  the  right.  Tickling 
the  soles  of  the  feet  causes  excessive  reflex. 

"The  patellar  tendon  reflex  is  exaggerated  in  each  knee. 
There  is  foot  clonus  in  both  extremities,  but  on  the  right  side 
more  than  the  left.  He  is  able  to  walk  about  a  quarter  of  a 
mile. 

"  The  functions  of  the  bladder  are  not  impaired. 

"  There  is  no  loss  of  cutaneous  sensibility  anywhere. 

"  The  patient  says  that  he  has  had  no  pains  at  any  time  in 
his  arms  or  legs,  except  a  little  pain  in  the  stiff  shoulder- 
joints,  and  this  only  on  movement." 

In  all  probability  in  this  case  there  was  rupture  of  vertebral 
ligaments,  and  possibly  also  of  intervertebral  substance,  with 


ON   SOME   VARIETIES   OF   CERVICAL   PARAPLEGIA.      73 

haemorrhage.  There  may  have  been  displacement  also  or 
fracture  of  a  vertebra,  but  the  result  leaves  this  uncertain.  It 
is  clear  that  in  some  way  there  was  a  sudden  compression  of 
the  cord ;  and  it  is  probable  that,  although  the  source  of  this 
compression  has  gradually  been  removed,  the  cord  itself  has 
sustained  about  the  point  indicated  by  the  patient  some 
permanent  damage,  which  has  been  followed  by  secondary 
degeneration  of  the  lateral  columns. 

Case  IV. — Gradually  increasing  weakness  of  all  four  extremities ; 
head  rigidly  fixed  to  one  side ;  prominence  of  third  cervical 
spine ;  slight  paralysis  of  facial  muscles  and  of  palate ;  absence 
of  movement  of  diaphragm ;  respiration,  mainly  upper  thoracic; 
wide-spread  loss  of  cutaneous  sensibility ;  attack  of  double 
pneumonia ;  imminent  peril  to  life  ;  recovery  from  pulmonary 
affection ;  gradual  increase  in  power  of  limbs,  and  recovery  of 
movements  of  diaphragm. 

On  May  14th,  1879,  Mary  Ann  M ,  eat.  13,  was  brought 

to  the  National  Hospital,  Queen  Square,  with  gradually 
increasing  weakness  of  the  four  extremities,  and  was  admitted 
at  once  as  in-patient. 

The  following  notes  were  taken  by  Mr.  A.  E.  Broster,  Kesi- 
dent  Medical  Officer  : — 

"  She  came  from  a  miserable  hovel,  where  she  was  living  in 
great  poverty,  and  had  been  ill-fed.  For  a  few  months  in  the 
winter  she  had  been  in  a  situation  as  general  servant,  where 
she  had  to  work  very  hard,  and  lift  heavy  weights.  It  was  in 
December  1878,  whilst  thus  employed,  that  she  complained  of 
sore  throat,  for  which  she  applied  a  mustard-plaster,  and  then 
bathed  her  neck  in  cold  water  to  remove  the  stinging  which 
this  occasioned.  Next  day  she  had  a  stiff  neck.  Two  or 
three  days  later,  rain  came  through  the  ceiling  on  to  her  head 
and  body  whilst  she  was  asleep  in  bed.  This  was  followed  by 
pains  in  the  neck  and  shoulders  and  the  right  knee-joint. 
About  the  end  of  January  1879  the  right  hand  is  described 
as  having  been  swollen  and  blue.  The  thumb  is  said  to  have 
had  little  blisters  on  it.  About  a  week  later  the  right  arm 
got  bad,  and  then  her  shoulder  became  powerless.  A  few  days 
more  and  the  right  leg  began  to  fail,  and  at  the  end  of  March 


74       ON   SOME    VARIETIES   OF   CEHVICAL    PARAPLEGIA. 

she  was  forced  to  leave  her  place.  A  fortnight  before  her  admis- 
sion into  the  hospital  the  right  arm  had  got,  she  says,  to  its 
worst,  but  the  leg  was  still  continuing  to  become  more  feeble. 

"  During  the  last  week  or  ten  days  the  left  arm  has  failed, 
and  the  left  leg  has  been  getting  numb  and  weak.  For  three 
weeks  past  she  has  been  unable  to  walk  by  herself. 

"  The  following  was  her  state  on  admission : — 

"  The  head  is  rotated  to  the  right,  and  immovably  fixed  in 
this  position,  the  long  cranial  axis  being  at  an  angle  of  45°, 
with  the  inter-scapular  axis  on  a  plane  parallel  with  and  above 
the  latter.  The  third  cervical  spine  is  thought  to  be  some- 
what unduly  prominent,  and  slightly  displaced  to  the  left. 
Around  and  above  it  there  is  some  hard  thickening,  apparently 
beneath  the  muscles.  No  tenderness  is  experienced  except  at 
a  spot  in  a  line  with  and  below  the  right  mastoid  process. 

"  Mental  condition. — Normal. 

"  Special  senses. — Smell  more  acute  on  the  left  than  the  right 
side,  tested  by  sumbul  and  assafoetida. 

"  Sight. — Beads  1\.  Snellen  left  eye,  5£  right  eye.  Ophthal- 
moscope shows  no  change. 

"  Hearing. — Normal. 

"  Taste. — Somewhat  deficient  on  both  sides,  but  especially  on 
the  left. 

"  The  upper  lip  has  a  somewhat  expressionless  look.  When 
she  smiles,  the  two  angles  of  the  mouth  act  evenly  and  fairly, 
but  in  voluntary  effort,  as  e.g.  in  showing  her  teeth,  there  is 
decided  weakness  on  both  sides,  most  marked  on  the  left.  She 
cannot  frown.  She  says  she  bites  her  right  lower  lip.  Asked 
to  shut  her  eyes,  the  lids  fail  to  meet  by  ^-inch,  but  by  a 
strong  effort  and  the  aid  of  other  facial  muscles  she  can 
approximate  them.  The  reaction  to  faradism  of  the  facial 
muscles  is  normal. 

"  The  right  masseter  is  thought  to  be  somewhat  stronger 
than  the  left,  the  horizontal  movement  of  the  lower  jaw  is 
good. 

"The  movements  of  the  eyeballs  are  perfect.  There  has 
been  no  diplopia.  Pupils  are  equal,  moderate  in  size,  and 
react  well  to  light. 

"  She  speaks  clearly,  there  is  slight  tremor  of  the  tongue. 


ON   SOME   VARIETIES   OF   CERVICAL   PARAPLEGIA.      75 

Swallowing  is  imperfect,  but  liquids  have  never  returned 
through  the  nose.  The  palate  goes  up  more  on  the  left  than 
the  right  side.     Uvula  deviates  to  the  left. 

"  Tonsils  are  large  and  somewhat  reddened.  A  small  ulcer 
seen  on  the  left. 

"  Laryngeal  movements  normal.  She  is  unable  to  move  her 
head  in  any  direction  whatever. 

"  Trunk. — Kespiratory  movements.  She  says, '  I  cannot  take 
my  breath  so  quick  as  I  used  to.  Sometimes  I  cannot  draw 
a  long  breath  for  two  or  three  minutes,  although  I  feel  I  want 
to.'     She  takes  a  number  of  short  inspirations. 

"  When  the  hand  is  placed  on  the  epigastric  region,  and  the 
patient  takes  as  deep  an  inspiration  as  possible,  the  abdominal 
wall  is  felt  to  fall  in  with  the  inspiration.  There  is  very  little 
movement  of  the  ribs.  There  is  no  incontinence  of  urine  or 
faeces. 

"  Upper  extremities. — The  right  is  very  stiff,  but  no  pain  is 
caused  by  passive  extension.  There  is  '  clasp-knife '  rigidity 
at  the  elbow-joint.  She  can  just  slightly  flex  this  joint,  and 
there  is  a  faint  power  of  grasp  with  the  right  hand. 

"  She  can  place  her  left  hand  on  the  top  of  her  head,  but  the 
grasp  of  this  hand  is  not  sufficient  to  affect  the  dynamometer. 

"The  forearms,  which  are  equal  in  size,  measure  7£  inches 
at  their  greatest  circumference.  In  the  hands  there  is  hyper- 
extension  of  the  metacarpo-phalangeal  joints,  owing  to  weak- 
ness of  the  interossei,  especially  marked  on  the  right  side. 
There  is  no  diminution  of  excitability  to  faradism  in  the 
muscles  of  either  arm.  From  the  drooping  position  of  the 
wrists  (especially  the  right)  there  is  evidently  weakness  of  the 
extensors. 

"  Lower  extremities. — The  patient  can  just  stand  ;  she  cannot 
walk.  There  is  marked  '  clasp-knife '  rigidity  in  the  right 
much  more  than  in  the  left.  As  she  lies  she  can  lift  the  left 
leg  off  the  bed,  not  the  right,  and  can  draw  up  both  legs,  the 
left  most  strongly.  Calves  measure  10£  inches  each.  There 
is  no  foot  clonus  on  either  side.  The  patellar  tendon  reflex  is 
exaggerated,  and  is  more  marked  in  the  right  than  the  left 
limb. 

"  Cutaneous  sensibility  is  lost  in  the  tips  of  the  right  fingers, 


76       ON   SOME   VAKIETIES   OF   CERVICAL   PARAPLEGIA. 

front  of  the  right  thigh,  dorsum  of  the  right  foot,  and  the 
right  shin.  It  is  diminished  over  the  trunk  and  extremities 
generally",  from  the  neck  downwards  behind,  and  from  2  inches 
below  the  level  of  the  clavicles  in  front,  with  the  following 
exceptions.  Along  the  ulnar  border  of  the  anterior  aspect  of 
the  right  forearm  there  is  scarcely  any  diminution.  Here  there 
is  distinct  hyperalgesia  to  the  induced  current.  The  left 
upper  arm  is  nearly  normal  as  to  its  sensibility. 

"  There  is  no  alteration  of  sensibility  in  the  face,  nor  in  the 
soles  of  the  feet. 

"  The  patient  complains  of  no  pain  anywhere,  but  of  a  sensa- 
tion of  pins  and  needles  in  the  forearms." 

Family  history. — Her  mother  has  twice  miscarried  at  the 
third  month.  The  father  has  had  no  signs  of  syphilis,  but  had 
a  gonorrhoea  in  youth.  The  other  children  show  no  signs  of 
congenital  syphilis.  A  brother  died,  four  days  before  this  girl 
attended  the  hospital,  of  rheumatism  and  bronchitis.  Neither 
he  nor  any  other  member  of  the  family  suffered  from  a  bad 
throat.  There  was  no  illness  at  the  place  where  the  patient 
lived  as  servant. 

The  patient  had  scarlet  fever  in  infancy.  Never  had  acute 
rheumatism,  nor  glandular  swellings,  nor  injury  by  accident. 

Viscera  healthy.  Temperature  normal.  The  treatment  was 
rest  in  bed  and  iodide  of  potassium.  In  the  course  of  four 
days  there  was  a  good  deal  of  improvement,  both  legs  could 
be  lifted  off  the  bed,  and  there  was  some  increase  of  power  in 
the  arms.  The  head,  too,  could  be  turned  a  little  to  the  right 
and  left,  and  bent  forward  a  very  little.  The  breathing  re- 
mained as  before,  and  Mr.  Broster  notes,  "  The  pectorals  and 
sterno-mastoids  seem  to  do  the  work." 

A  gutta-percha  support  was  fixed  to  the  head  and  neck. 

On  June  12th  it  is  noted  that  "  during  the  last  two  days 
the  patient  has  complained  of  pain  in  the  right  leg,  shooting 
down  from  the  groin  to  the  knee,  and  there  has  been  more 
difficulty  in  swallowing.     There  is  wasting  of  the  interossei." 

Next  day  there  was  orthopncea,  the  respirations  very  rapid, 
and  entirely  upper  thoracic.  There  was  some  cyanosis. 
These  symptoms  increasing  on  the  following  day,  the  head- 
gear was  removed,  as  it  was  thought  it  might  interfere  with 


ON   SOME   VAEIETIES   OF   CERVICAL   PAEAPLEGIA.       77 

the  action  of  the  sterno-mastoids.  Auscultation  showed 
tubular  breathing  and  crepitant  rales  along  the  base  of  the  left 
lung,  with  harsh  respiration  in  the  right  lung.  There  was 
very  slight  cough.  The  alae  nasi  napped.  Her  temperature 
was  101  •  4. 

On  the  evening  of  the  15th  her  temperature  was  103,  the 
pulse  130,  dicrotous.  Respirations  36.  She  was  very  cyanotic. 
There  were  crepitant  rhonchi  throughout  the  left  lung  behind, 
and  along  the  axillary  border  of  the  right.  There  was  some 
delirium.  Deglutition  was  much  impaired,  so  that  she  could 
only  swallow  very  small  quantities  of  fluid.  With  great  diffi- 
culty and  gasping  she  stated  that  there  was  some  pain  in  her 
head.  At  this  time  death  appeared  inevitable.  After  this 
there  was  gradual  improvement  in  the  respiratory  system,  but 
the  loss  of  power  in  the  extremities  was  at  first  more  pro- 
nounced than  it  had  been  before  the  commencement  of  the 
pneumonic  attack. 

On  the  18th  I  observed  that  the  left  side  of  the  chest  moved 
a  little  more  than  the  right ;  the  movement  being  mainly  an 
elevation  of  the  upper  ribs ;  there  was  but  very  little  lateral 
expansion.     The  epigastrium  sank  during  inspiration. 

On  June  27th  it  is  noted  that  the  temperature  is  100° ;  the 
respiration  mainly  upper  thoracic,  but  with  a  little  unilateral 
expansion.  Over  the  base  of  the  left  lung  the  percussion  note 
was  dull,  and  there  was  increased  vocal  fremitus.  Moist 
bubbling  and  crackling  rales  could  be  heard.  On  the  right  side 
there  were  a  few  small  mucous  rales  along  the  posterior  border. 

Both  legs  could  now  be  moved  freely  ;  each  could  be  lifted 
off  the  bed  and  held  extended  for  about  thirty  seconds. 

By  the  middle  of  July  all  traces  of  the  pneumonic  attack 
had  subsided.  There  was  gradual  improvement  in  the  paralysed 
limbs.  In  the  middle  of  September  she  had  so  far  recovered 
that  she  was  able  to  be  sent  to  the  Convalescent  Establish- 
ment at  Finchley,  and  the  following  note  of  her  condition  was 
then  taken  : — "  She  carries  her  head  in  the  same  '  side  way '  as 
on  admission,  and  has  gained  no  power  as  yet  over  its  move- 
ments. She  cannot  look  over  her  shoulder.  The  thickening 
previously  described  is  very  distinct  around  and  over  the  third 
cervical  spine.     This  spine  can  be  felt  distinctly  prominent 


78      ON   SOME   VARIETIES  OP   CERVICAL   PARAPLEGIA. 

beyond  the  other  cervical  spines.  The  weakness  described  in 
the  facial  muscles  remains  in  statu  quo,  except  that  she  can 
approximate  her  eyelids  a  little  more  than  she  could  formerly. 
There  is  some  deviation  of  the  uvula  to  the  left.  The  tonsils 
are  large.  The  respiration  is  entirely  thoracic,  no  movement 
of  the  diaphragm  being  perceptible. 

"  Upper  limbs. — Bight. — She  can  flex  her  elbow  ;  the  limb 
is  slightly  stiff.  There  is  a  perceptible,  but  not  measurable, 
grasp  of  the  hand.  No  distinct  wasting  of  muscles.  She  can 
raise  the  arm  to  the  level  of  the  shoulder. 

"  Left. — She  can  hold  up  the  arm  fairly.  The  grasp  of  hand 
is  not  measurable.  She  can  feed  herself,  and  cut  up  meat,  but 
cannot  dress  herself. 

"  Lower  limbs. — She  can  stand  and  walk ;  the  calves  each 
measure  ten  inches  in  circumference.  The  walking  is  per- 
formed in  a  shaky  manner,  the  trunk  held  stiffly,  and  the 
knees  bent.  She  does  not  drag  her  feet.  In  rising  from  a 
chair  she  appears  to  have  much  difficulty,  and  requires  a  little 
impetus  before  she  can  get  on  to  her  legs. 

"  The  patellar  tendon  reflex  is  exaggerated  on  each  side. 
Foot-clonus  is  present,  though  not  to  a  very  marked  extent,  in 
both  limbs — in  the  right  more  than  in  the  left. 

"  Cutaneous  sensibility. — On  the  left  hand  and  forearm  (except 
in  the  tips  of  the  fingers,  which  are  still  numb)  sensation  is 
normal.     On  the  left  leg  it  is  deficient. 

"  Bight  upper  limb. — Sensibility  is  still  deficient,  though 
less  so  than  formerly.  On  the  right  leg  it  is  as  good  as  on 
the  face,  where  it  is  apparently  unimpaired. 

"  For  her  own  part,  the  patient  says  that  the  sensation  in 
the  left  lower  limb  is  better  than  it  was ;  and  that  in  the  right 
leg,  which  used  to  be  the  worst,  she  feels  better  than  in  the 
left.  The  right  leg,  which  was  the  weaker,  is  now,  she  says, 
the  stronger.  She  says  that  a  touch  upon  her  back  is  felt 
quite  right,  but  not  so  on  the  front  of  the  body.  She  has  no 
pains  whatever,  and  no  sensations  of  '  pins  and  needles.' 

"  Appetite  good.  She  has  control  over  the  sphincters.  Two 
months  and  a  half  later,  whilst  at  Finchley,  she  was  well  able 
to  get  about  by  herself.  The  movement  of  the  diaphragm  had 
returned." 


ON   SOME   VARIETIES   OF   CERVICAL   PARAPLEGIA.     79 

My  first  impression,  on  seeing  this  patient  in  the  out-patient 
room,  was  that  we  had  to  do  with  one  of  those  acute  cases 
of  nearly  universal  paralysis,  the  pathology  of  which  remains 
obscure,  and  of  which  I  have  brought  two  marked  examples 
before  the  Clinical  Society  of  London.  One  had  to  consider 
the  possibility  also,  in  view  of  the  history  of  "  sore  throat,"  that 
the  affection  might  be  diphtherial.  Both  these  contingencies 
were  disposed  of  by  the  observation  of  the  fixed  position  of 
the  head,  and  the  discovery  of  the  thickening  about  the 
third  cervical  spine.  The  case  resolves  itself,  therefore,  in  all 
probability,  into  one  of  Pott's  disease,  high  up  in  the  cervical 
region.  If  this  be  so,  the  internal  lesion  (pachymeningitis), 
besides  cutting  off  nervous  impulses  from  the  extremities, 
ribs,  and  diaphragm,  apparently  involves  also  to  a  certain 
extent  the  origins  of  the  facial  and  glossopharyngeal  nerves. 

The  pains  were  not  strongly  marked.  Such  as  were  present 
affected  the  head,  doubtless  through  the  occipital  nerves. 

The  most  interesting  point  in  this  remarkable  case  is  the 
long-continued  paralysis  of  the  diaphragm.  This  paralysis 
was  doubtless  only  partial,  like  the  paralysis  of  the  extremi- 
ties and  of  the  intercostals ;  but  it  was  pronounced  enough 
to  give  rise  to  the  abdominal  depression  during  inspiration 
mentioned  by  Duchenne  as  characteristic  of  paralysis  of  this 
muscle.  Duchenne  thus  describes  the  condition.  "  At  the 
moment  of  inspiration  the  epigastrium  and  the  hypochondria 
are  depressed,  whilst,  on  the  other  hand,  the  chest  dilates ;  the 
movements  of  these  parts  are  reversed  during  expiration." 
Kecovery  from  such  an  attack  of  pulmonary  inflammation  as 
this  girl  suffered  must,  in  the  circumstances  of  her  case,  be  an 
exceedingly  rare  event. 


80  DISTRIBUTION    OF   THE    ARTERIES   OP 


DISTRIBUTION  OF  THE   ARTERIES  OF  THE 
SPINAL   CORD. 

BY   JAMES   ROSS,  M.D., 
Assistant-Physician,  Manchester  Boyal  Infirmary. 

A  comparison  of  fortunate  sections  of  the  spinal  cord  lias 
enabled  me  to  map  out  pretty  accurately  the  distribution  of 
its  vessels.  The  anterior  median,  the  posterior  spinal,  and  the 
central  arteries  are  already  well  described  in  ordinary  anato- 
mical works,  and  need  only  be  mentioned  here. 

The  anterior  median  artery  gives  a  series  of  small  branches, 
which  pass  backwards  in  the  anterior  median  fissure,  to  reach 
the  anterior  commissure.;  hence  these  vessels  may  be.  called 
the  arteries  of  the  anterior  median  fissure  (Fig.  1,  af).  Each 
of  these  vessels  on  reaching  the  anterior  commissure  divides 
into  two  main  trunks,  each  of  which  enters  the  grey  sub- 
stance of  the  anterior  horns,  and  which  may  be  called  the 
arteries  of  the  anterior  commissure  (Fig.  1,  ac).  Each 
trunk  subdivides  into  three  branches,  which,  from  their 
position,  may  respectively  be  named  the  anterior  (Fig.  1, 1), 
median  (Fig.  1,  1'),  and  posterior  (Fig.  1,  1")  branches  of 
the  artery  of  the  anterior  commissure.  The  anterior  branch 
curves  forwards,  and  is  distributed  to  the  anterior  and  internal 
portion  of  the  grey  substance ;  the  median  is  distributed  to 
the  lateral  portion  of  the  anterior  horn,  while  the  posterior  is 
directed  backwards  to  the  posterior  horn.  The  central  artery 
also  gives  off  an  anterior  (Fig.  1,  2)  median  (Fig.  1,  2')  and 
posterior  (Fig.  1,  2")  branch,  which  are  distributed  respectively 
to  the  anterior,  lateral  and  posterior  portions  of  the  grey 
substance.  The  median  branches  of  the  two  main  vessels, 
besides  supplying  the  grey  substance,  are  also  distributed  to 


THE   SPINAL   CORD. 


81 


the   pyramidal   tract  of  the  lateral  column.      The  posterior 
spinal  artery  (Fig.  1,  p  a)  gives  off  branches,  which  pass  by  the 


7JIT 


Fig.  1. — Schematic  Representation  op  the  Distribution  op  the  Blood- 
Vessels  in  the  Cord.* 


Anterior  median  artery. 

af  Arteries  of  the  anterior  median  fissure. 

a  c  Artery  of  the  anterior  commissure. 

1  Anterior  branch. 
1'  Median  branch. 
1"  Posterior  branch. 

c  a  Central  artery. 

2  Anterior  branch. 
2'  Median  branch. 
2"  Posterior  branch. 

pa  Posterior  root  arteries. 
6  6' 6"  Arteries  of  posterior  horns, 
t  a  Internal  anterior  root  artery. 
e  a  External  anterior  root  artery. 

3  3'  Internal  and  external  branch. 


a  r  Antero-lateral  branches. 

4  Anterior  branch. 

m  r  Median  lateral  artery. 

5  5'  Anterior  and  posterior  branches. 
p  r  Posterior  lateral  arteries. 

ip  Internal  posterior  artery. 
mp  External  posterior  artery. 

g  Arteries  of  the  column  of  Gull. 
p  c  Artery  of  the  posterior  commissure. 
v  c  Vascular  column  of  Clarke. 

i  Internal  group  of  cell3. 

a  Anterior  group. 
n  I  Antero-lateral  group. 
p  I  Postero-lateral  group. 

c  Central  group. 

m  Median  group. 


side  of  the  posterior  roots  to  enter  the  grey  substance  of  the 
posterior  horns,  where  they  subdivide  into  a  variable  number 
of  small  branches  (Fig.  1,  6  6'  6"),  which  may  be  called  arteries 

*  I  have  to  thank  Dr.  Young,  of  the  Owens  College,  for  the  above  diagram. 
VOL.    III.  G 


82  DISTRIBUTION   OF   THE   ARTERIES  OF 

of  the  posterior  horns.  In  addition  to  the  vessels  just  de- 
scribed, a  large  number  pass  from  the  pia  mater  into  the 
substance  of  the  cord,  and  some  of  these  are  so  large  and  so 
constant  as  to  deserve  special  mention.  Two  of  these  run  by 
the  side  of  the  bundles  of  fibres  which  constitute  the  anterior 
roots  of  the  nerves,  hence  they  may  be  called  the  anterior- 
root  arteries.  The  branch  nearest  the  median  fissure  may  be 
called  the  internal  anterior  root  (Fig.  l,ia),  and  the  other  the 
external  anterior-root  (Fig.  1,  ea)  artery.  The  internal  artery 
on  entering  the  grey  substance  joins  the  anterior  branches 
of  the  first  subdivision  of  the  artery  of  the  anterior  median 
fissure  and  of  the  central  artery.  The  external  anterior-root 
artery  on  entering  the  grey  substance  subdivides  into  two 
branches,  the  inner  (Fig.  1,  3)  of  which  is  distributed 
along  with  the  vessels  just  mentioned,  while  the  outer 
branch  (Fig.  1,  3')  passes  between  what  we  may  call  the 
antero-lateral  (Fig.  1,  al)  and  central  groups  (Fig.  1,  c) 
of  cells.  A  very  constant  vessel  passes  to  the  grey  sub- 
stance from  the  pia  mater,  at  the  point  of  junction  of  the 
anterior  and  lateral  columns  of  the  cord,  and  it  may  therefore 
be  called  the  antero-lateral  artery  (Fig.  1,  a  r).  On  reaching 
the  grey  substance  it  frequently  divides  into  three  branches, 
one  of  which  passes  in  front  (Fig.  1,  4),  another  behind,  and 
another  into  the  substance  of  the  antero-lateral  group  of  cells. 
Another  constant  vessel  (Fig.  1,  m  r)  passes  from  the  lateral 
aspect  of  the  cord,  and  on  reaching  the  grey  substance  it  sub- 
divides into  two  branches,  the  one  of  which  passes  in  front  and 
the  other  behind  the  postero-lateral  group  of  cells  (Fig.  1, 
f  V),  and  this  vessel  may  from  its  position  be  called  the 
median-lateral  artery.  Small  branches  (Fig.  l-,pr)  pass  at 
short  intervals  from  one  another  through  the  posterior  part  of 
the  lateral  column,  and,  together  with  the  median  branches  of 
the  first  subdivision  of  the  artery  of  the  anterior  median  fissure, 
and  of  the  central  arteries,  supply  the  posterior  part  of  the 
lateral  columns ;  hence  these  vessels  may  be  called  posterior- 
lateral  arteries.  Two  vessels  pass  from  the  pia  mater  into  the 
substance  of  the  posterior  column,  the  one  nearest  the  pos- 
terior median  fissure,  and  which  may  therefore  be  called  the 
internal  posterior  artery  (Fig.  1,  ip),  passes  between  the  column 


THE   SPINAL   CORD.  83 

of  Goll  and  the  posterior  root  zone  ;  and  after  passing  through 
about  two-thirds  of  the  depth  of  the  posterior  column,  it  curves 
outwards  to  reach  the  posterior  grey  horn.  The  other  vessel 
may  be  named  the  external  or  median  posterior  artery  (Fig.  1, 
mp) ;  it  passes  into  the  substance  of  the  posterior  column  at 
the  middle  of  the  posterior  root  zone,  and  on  reaching  about 
one-third  the  depth  of  the  posterior  column,  it  also  curves 
outwards  to  reach  the  posterior  grey  horn,  where  it  terminates. 
Small  vessels  (Fig.  1,  g)  pass  from  the  pia  mater,  in  the  poste- 
rior-median fissure,  into  the  substance  of  the  column  of  Goll. 

Another  vessel,  which  may  be  called  the  artery  of  the  pos- 
terior commissure  (Fig.  l,pc),  passes  from  the  pia  mater  along 
the  posterior  margin  of  the  posterior  commissure,  and  winds 
backwards  along  the  internal  edge  of  the  posterior  horn. 

With  regard  to  the  groups  of  cells  in  the  anterior  horns,  I 
have,  on  the  whole,  followed  the  classification  of  Erb.  These 
groups  are  the  vesicular  column  of  Clarke  (v  c),  the  postero- 
lateral (p  I),  and  the  antero-lateral  groups  (a  I).  The  group 
which  Erb  calls  anterior,  I  propose  to  call  internal  (i),  because 
a  very  constant  group  of  caudate  cells  is  always  observed 
near  the  anterior  roots,  which  from  its  position  is  best  distin- 
guished as  the  anterior  group  (a).  Also  the  group  which  Erb 
calls  the  median,  I  propose  to  call  the  central  (c),  because  I 
wish  to  distinguish  a  very  important  area  (m),  which  has 
hitherto  not  been  described,  and  which  from  its  position 
and  connections  is  best  denominated  the  median  area.  The 
cells  of  the  median  area  are  caudate,  but  they  are  much 
smaller  than  those  of  the  other  groups.  This  area  is  only 
present  in  the  cervical  and  lumbar  enlargements,  the  portions 
of  the  cord  which  regulate  the  movements  of  the  limbs ;  its 
relatively  larger  size  differentiates  the  anterior  grey  horn  of 
the  cervical  enlargement  of  the  adult  human  cord  from  the 
lumbar  enlargement ;  in  the  human  embryo  at  the  fifth  month 
and  in  the  cord  of  the  ox  and  dog,  this  area  is  of  the  same 
relative  size  in  both  the  cervical  and  lumbar  enlargements, 
and  the  anterior  horns  are  under  such  circumstances  almost 
indistinguishable;  hence  it  may  be  presumed  that  in  the 
median  area  are  mainly  organised  the  complicated  movements 
which  distinguish  the  hand  of  man  from  the  anterior  extremity 

g  2 


84     DISTRIBUTION  OF  THE  ARTERIES  OF  THE  SPINAL  CORD. 

of  the  lower  animals,  so  far  as  these  movements  are  represented 
in  the  spinal  cord.  Other  interesting  facts  tending  to  the 
same  conclusion  are  that  the  cells  of  the  median  area  in  the 
human  cord  only  assume  processes  after  birth  ;  while  those  of 
the  other  groups  possess  distinct  processes  at  the  fifth  month 
of  embryonic  life. 

The  median  area  is  entirely  absent  in  the  upper  cervical 
and  dorsal  portions  of  the  cord,  and  consequently  the  internal, 
anterior,  antero-lateral,  and  central  groups  approximate,  so  that 
they  are  not  always  readily  distinguishable.  In  these  regions, 
however,  an  area  is  interposed  in  the  human  cord  between  the 
antero-lateral  and  postero-lateral  groups,  which  possess  some  of 
the  characteristics  of  the  median  area  in  the  cervical  region. 
The  cells  of  this  area  are  relatively  small,  they  are  compara- 
tively late  in  development,  and  do  not  possess  distinct  processes 
at  birth  ;  and  the  area  is  entirely  unrepresented  in  the  cord  of 
the  ox  and  dog;  hence  it  may  be  inferred  that  this  area 
represents  the  additional  organisation  rendered  necessary  by 
the  maintenance  of  the  erect  posture  in  man. 

It  may  be  readily  imagined  that  in  all  inflammatory  diseases 
the  tissues  in  the  vicinity  of  the  vessels  will  be  more  liable 
than  the  remote  portions  to  be  inundated  by  effusion ;  hence 
the  lines  of  the  distribution  of  the  vessels  may  be  said  to  form 
lines  of  least  resistance  to  disease.  It  is  also  worthy  of  remark 
that  the  development  of  the  cells  proceeds  from  the  centres  of 
the  groups  to  their  margins,  and  that  in  progressive  degenera- 
tive diseases,  the  degeneration  proceeds  from  the  margins  of 
the  groups  to  their  centres.  To  this  law  the  median  area  in  the 
lumbar  and  more  especially  in  the  cervical  enlargement  and 
that  which  lies  between  the  antero-lateral  and  postero-lateral 
groups  in  the  dorsal  and  upper  cervical  regions,  are  apparent 
exceptions.  These  areas,  although  containing  cells,  can  hardly 
be  called  groups  ;  they  are  probably  areas  where  the  marginal 
cell  of  the  real  groups  meet.  But  whatever  may  be  their 
nature  they  are  the  most  vulnerable  portions  of  the  cord,  and 
as  they  axe  the  last  to  be  developed,  so  they  manifest  the 
greatest  liability  to  disease. 


<£rittail  gigesfs  ant)  gotices  of  |>oohs. 


Nothnagel  on  the  Regional  Diagnosis  of  Diseases  of  the  Brain. 
(Topische  Diagnostik  tier  Gebirnkraukheiten.  Eine  Kli- 
nisclie  Studie.  Von  Dr.  Hermann  Nothnagel.  Berlin,  1879. 
Hirschwald,  8vo.  pp.  626.) 

This  is  an  exceedingly  able  and  important  work,  and  worthy 
of  the  author's  reputation  as  a  physiologist  and  physician. 
It  is  an  elaborate  collection  and  digest  of  the  more  important 
facts  and  observations  relating  to  the  regional  diagnosis  of 
diseases  of  the  encephalic  centres,  from  the  medulla  oblongata 
up  to  the  cerebral  cortex  and  its  individual  parts.  After 
recording  and  analysing  the  clinical  facts  bearing  on  disease 
of  each  particular  region,  the  author  sums  up  the  conclusions 
which  he  considers  they  justify  in  a  series  of  lucid  diagnostic 
propositions. 

Though  naturally  the  work  is  largely  of  the  nature  of  a 
compilation,  yet  the  author  displays  much  originality  and 
critical  acumen,  and  the  whole  bears  impress  of  a  mind  tho- 
roughly capable  of  dealing  with  every  detail.  It  professes  to 
deal  only  with  the  clinical  aspect  of  the  question.  Physio- 
logical and  anatomical  considerations  are  reserved  for  treat- 
ment in  a  separate  work.  This  will  no  doubt  be  looked  for 
with  interest  by  all  who  believe  that  anatomy,  experimental  phy- 
siology, and  classical  medicine  ought  mutually  to  support  and 
shed  light  on  each  other.  As  to  the  propriety  or  even  possi- 
bility of  entirely  abstracting  from  anatomical  and  physiological 
researches  in  a  work  devoted  to  the  regional  diagnosis  of  cerebral 
lesions,  and  therefore  by  implication  determining  the  functions 
of  the  parts  involved,  there  may  be  some  difference  of  opinion. 
It  may  be  possible,  and  perhaps  advisable,  to  avoid  entering 


86  CEITICAL   DIGESTS   AND 

at  length  into  these  topics,  but  to  exclude  them  entirely  is 
not  capable  of  being  carried  out ;  and  in  truth  it  may  be  as- 
serted that  but  for  the  light  of  physiological  research,  clinical 
facts  relating  to  cerebral  disease  would  still  be  largely  in  a 
state  of  chaos.  And  certainly  if  the  clinical  evidence  here 
furnished  were  all  the  basis  on  which  the  diagnostic  proposi- 
tions are  based,  we  should  have  to  regard  the  foundation  as  in 
many  respects  of  an  exceedingly  slender  character.  Through- 
out the  whole  of  this  work,  in  fact,  the  experimental  physiolo- 
gist is  clearly  visible,  and  not  unfrequently  we  find  a  tendency 
to  draw  conclusions,  evidently  in  favour  of  some  theory  other- 
wise arrived  at,  from  clinical  facts  which  are  neither  sufficiently 
numerous  nor  of  such  a  nature  as  to  justify  any  conclusion 
whatever.  That  which  renders  analysis  and  conclusions  from 
clinical  facts  alone  extremely  difficult  and  even  hazardous,  is 
the  extreme  complexity  of  the  conditions,  and  the  impossibility 
of  distinguishing  in  all  cases  between  direct  and  indirect 
effects  of  lesions.  Though  Nothnagel  adopts  Charcot's  rules 
as  to  the  necessity  of  excluding  all  cases  where  the  lesions  are 
of  such  a  nature  as  obviously  to  produce  general  perturbation 
and  far-reaching  disturbance,  and  to  consider  as  bearing  on 
regional  localisation  only  such  lesions  as  are  not  likely  to 
cause  such  indirect  effects ;  yet  this  from  a  purely  clinical 
point  of  view  is  very  difficult  to  carry  out.  Brown-Sequard's 
reading  of  clinical  facts  has  led,  as  is  well  known,  to  conclu- 
sions very  different  from  those  usually  accepted  and  here 
advocated.  And  we  see  in  our  author  but  too  frequently  an 
assumption  of  indirect  action  where  the  clinical  facts  are  at 
variance  with  his  own  hypothesis,  and  ignoring  it  when  it 
might  be  highly  important  to  take  it  into  consideration.  That 
the  conclusions  of  Nothnagel  will  be  more  readily  accepted 
than  those  of  Brown-Sequard  will  depend  not  merely  on  the 
clinical  evidence  here  adduced,  but  on  evidence  otherwise 
obtained,  and  under  the  circumstances  indispensable. 

Our  author,  however,  occasionally  forgets  another  very  impor- 
tant principle,  though  he  does  acknowledge  its  validity,  viz. 
to  found  no  conclusions  as  to  the  effects  of  certain  lesions 
unless  these  effects  are  constant  or  their  absence  satisfactorily 
accounted  for.     Negative  instances,   cases  of  lesions  without 


NOTICES  OP   BOOKS.  87 

such  symptoms,  are  sufficient  to  overturn  a  whole  host  of 
positive  instances,  where  the  facts  seem  to  establish  a  causal 
relation  between  the  lesion  and  the  symptoms,  while  in  reality 
the  symptoms  are  dependent  on  some  other  condition.  The 
history  of  the  localisation  of  cerebral  disease  shows  how  pre- 
carious conclusions  from  clinical  evidence  alone  have  been,  the 
conditions  of  strictly  scientific  evidence  not  having  been 
fulfilled. 

The  manner  in  which  our  author  in  his  first  chapter  treats 
of  diseases  of  the  Cerebellum  strongly  suggests  the  idea  that 
his  chief  object  is  to  prove  by  clinical  facts  that  it  is  only  the 
middle  lobe  that  is  concerned  in  the  co-ordination  of  equi- 
librium, &c,  and  that  the  disorders  characteristic  of  cerebellar 
disease  only  occur  where  the  middle  lobe  is  implicated. 

The  characteristic  symptoms  of  cerebellar  disease  are  a 
reeling  and  staggering  gait  and  vertigo.  These,  however, 
are  not  absolutely  pathognomonic  of  cerebellar  disease,  as  they 
may  occur  from  other  affections  of  the  central  nervous  system. 
The  diagnosis  must  take  other  negative  and  positive  phe- 
nomena into  consideration.  As  accessory  symptoms,  but  not  due 
to  the  cerebellar  lesion  as  such,  we  have  the  general  phenomena 
indicative  merely  of  intracranial  disease,  particularly  tumours, 
viz.  headache,  vomiting,  optic  neuritis ;  and  others  produced 
indirectly,  such  as  affection  of  speech,  affections  of  cranial 
.nerves,  and  general  motor  disturbances  paralytic  or  spastic. 

The  special  symptoms  are  in  all  cases  referred  to  impli- 
cation of  the  middle  lobe,  either  directly  or  indirectly. 

What  the  standard  is  by  which  the  author  discriminates 
between  direct  and  indirect  action  is  very  difficult  to  discover 
from  a  study  of  the  facts  here  presented,  as  well  as  from  others 
which  might  be  referred  to.  It  has  the  appearance  of  being 
extremely  arbitrary  and  dogmatic.  It  may  be  admitted,  and 
clinical  facts  certainly  favour  the  view,  that  lesions  of  the 
middle  lobe  are  more  frequently  associated  with  cerebellar 
symptoms  than  when  the  lesion  is  in  the  lateral  lobe,  but 
this  is  very  far  from  carrying  with  it  the  conclusion  here 
maintained,  that  the  middle  lobe  alone  exercises  those  functions 
generally  looked  upon  as  cerebellar.  Another  explanation 
and  one  more  in  accordance  with  physiological  facts,  which, 


88  CKITICAL  DIGESTS  AND 

though  not  mentioned,  cannot  be  ignored,  is  that  a  lesion  of 
the  middle  lobe  is  more  likely  to  derange  the  cerebellum  as  a 
whole  by  affecting  all  its  lobes  at  once.  Our  author  even 
thinks  that  the  facts — more  particularly  those  relating  to 
atrophy  of  the  cerebellum — warrant  him  in  advancing  the 
hypothesis  that  the  lateral  lobes  are  "  somehow  related  to  the 
psychical  functions."  This  hypothesis  is,  it  is  true,  stated 
with  some  reserve ;  but,  considering  the  kind  of  evidence 
offered,  it  would  have  been  better  perhaps  to  reserve  it 
altogether. 

Though  several  of  the  accessory  phenomena,  obviously 
dependent  on  indirect  action  on  other  structures,  such  as 
motor  paralysis,  spasms,  &c,  are  mentioned  as  occurring  in 
connection  with  cerebellar  lesions,  it  seems  somewhat  strange 
that  no  particular  notice  is  taken  of  the  rigidity  and  tetanic- 
like  seizures  described  so  carefully  by  Hughlings- Jackson  in 
connection  with  cerebellar  tumours,  so  characteristic  as  to  be 
almost  pathognomonic.  Even  though  indirect,  these  phe- 
nomena are  of  exceeding  value  in  a  diagnostic  point  of  view, 
and  too  important  to  be  dismissed  among  minor  accessory 
symptoms. 

The  chapter  on  the  cerebellum  is  certainly  not  the  most 
satisfactory  in  the  book. 

As  regards  lesions  of  the  crura  cerebelli,  the  clinical  facts  do 
not  allow  us  to  decide  positively  as  to  the  effects  of  lesions  of 
the  anterior  or  posterior  peduncles  respectively.  Conclusions 
as  to  the  special  symptoms  of  lesions  of  the  middle  peduncles 
are  also  doubtful,  owing  to  the  fact  that  lesions  are  rarely  accu- 
rately circumscribed.  The  most  marked  phenomena  met  with 
are  distortion  of  the  axes  of  the  trunk,  head,  and  eyes — 
particularly  the  latter — with  vertigo  and  tendency  to  fall  to 
one  side.  These  our  author  looks  upon  as  purely  irritative 
phenomena,  as  in  one  case  at  least  (Nonat's)  the  symptoms  were 
not  permanent,  though  the  lesions  remained.  The  rotation 
may  be  towards,  or  away  from,  the  seat  of  lesion.  This  is  not 
explained,  though  a  fact  of  this  kind  might  suggest  doubt  as 
to  whether  the  symptoms  can  in  all  cases  be  regarded  as  purely 
irritative.  Destructive  and  irritative  lesions  would  be  the 
converse  of  each  other,  and  this  may  be  the  real  ground  of  the 


NOTICES   OF   BOOKS.  89 

difference  as  to  the  side  towards  which  rotation  occurs.     This, 
however,  the  author  does  not  take  into  consideration. 

Affections  of  the  Pons  Varolii  are  treated  separately  from 
those  in  which  the  medulla  oblongata  is  also  involved,  though 
the  two  centres  are  very  commonly  implicated  together. 

Haemorrhages  in  the  pons  are  rare  as  compared  with  those 
in  the  hemispheres.  Can  we  diagnose  with  certainty  a 
haemorrhage  into  the  pons  ?  Not  always,  says  our  author. 
The  chief  indication  is  the  fact  of  alternate  paralysis.  Thus 
an  apoplectic  attack,  with  alternate  paralysis  of  the  limbs  and 
face,  with  anarthria  and  dysphagia,  points  to  the  pons  as  the 
seat  of  lesion.  Of  great  importance  practically  are  signs  of 
motor  irritation,  in  the  form  of  general  epileptiform  convulsions, 
considered  pathognomonic  by  Ollivier.  These  convulsions 
Nothnagel  explains  by  irritation  of  his  so-called  "  convulsion 
centre,"  though  why  such  a  term  should  be  employed,  and  an 
animal  credited  with  a  centre  for  the  display  only  of  patho- 
logical effects,  it  is  not  easy  to  comprehend  without  an  abuse 
of  physiological  terms.  That  convulsions  should  readily  occur 
from  irritation  of  the  pons,  where  all  the  sensory  and  motor 
strands  of  the  encephalon  are  in  such  close  relation,  is  a  fact 
not  difficult  to  understand  without  the  questionable  aid  of 
such  an  objectionable  term.  These  convulsions,  however,  are 
not  constant,  and  Nothnagel  does  not  agree  with  Ollivier  in 
regarding  them  as  of  themselves  pathognomonic.  Vomiting  is 
common,  but  not  invariable.  The  state  of  the  pupils  in 
pontine  haemorrhage  is  one  to  which  great  importance  has  been 
attached.  Very  often  they  are  contracted.  Hence  this  con- 
dition, combined  with  complete  muscular  relaxation,  simulates 
narcotic  poisoning.  The  pupils,  however,  have  been  found 
dilated,  or  of  normal  size,  and  the  reaction  to  light  may  also 
vary.  Sudden  death — fulminating  apoplexy — is  not  un- 
common from  haemorrhage  into  the  pons,  probably  owing  to 
indirect  action  on  the  medulla  oblongata. 

Neither  the  occurrence  of  albuminuria,  nor  of  diabetes 
mellitus,  though  sometimes  met  with,  can  be  taken  as  constant 
in  pontine  lesions.  Similarly,  also,  as  regards  affections  of 
circulation  and  respiration.  These  latter  are  to  be  ascribed 
to  action  on  the  medulla  oblongata. 


90  CEITIOAL  DIGESTS  AND 

Prevost's  idea  that  in  pontine  haemorrhage  the  conjugate 
deviation  of  the  head  and  eyes  is  away  from  the  side  of  lesion 
instead  of  towards  it,  as  in  cerebral  haemorrhage,  is  not  sub- 
stantiated. 

As  a  general  result  it  is  stated  that  a  haemorrhage  into  the 
pons  can  only  be  diagnosed  with  certainty  "  when  there  is 
alternate  paralysis  of  the  face  and  extremities.  It  may  be 
considered  probable  when  the  apoplectic  attack  is  accom- 
panied by  irritative  motor-phenomena  in  the  form  of  general 
convulsions,  with  contracted  pupils,  and  when  death  occurs 
within  a  few  hours.  Under  all  other  circumstances  only 
conjectures  are  possible  "  (p.  105). 

Embolism  of  the  basilar  artery  is  stated  by  Nothnagel  not 
to  occur.  This,  however,  has  been  controverted  by  Gowers 
in  a  recent  communication  to  this  Journal.  ('  Brain,'  No. 
VIII.  "  Illustrations  of  Diseases  of  the  Pons  Varolii.")  Throm- 
bosis is  not  uncommon.  This  may  be  rapidly  fatal  or 
lead  to  chronic  softening,  with  "  herd-symptome."  These 
symptoms,  which  occur  with  haemorrhagic  or  necrotic  soften- 
ings, are  very  numerous. 

Motor  paralysis  of  the  limbs  on  the  side  opposite  the  lesion 
may  be  seen — more  marked  in  the  lower  than  upper  extre- 
mity— without  affection  of  cranial  nerves  ;  or  the  cranial  nerves 
may  alone  be  paralysed ;  but  more  commonly  there  is  alternate 
paralysis  of  the  extremities  on  the  opposite,  and  of  cranial 
nerves  on  the  same  side  as  the  lesion.  But  the  face  and  limbs 
may  be  paralysed  on  the  same  side.  This  occurs  when  the 
lesion  is  nearer  the  crus  cerebri ;  the  alternate  form  occurring 
when  the  lesion  is  nearer  the  medulla.  The  facial  paralysis 
in  pontine  lesions  resembles  peripheral  facial  paralysis,  both  as 
regards  the  diminution  of  faradic  excitability,  and  as  regards 
the  reaction  of  degeneration  to  galvanism. 

Besides  the  facial  we  may  have  affection  of  the  trigeminus, 
abducens,  (auditory?)  and  hypoglossal.  The  hypoglossal  is 
affected  next  in  frequency  to  the  facial,  and  then  the  abducens. 
The  affection  may  be  on  the  side  of  lesion  or  on  the  opposite. 
Whether  a  conjugate  ocular  paralysis  of  the  rectus  externus 
on  the  same  side,  and  rectus  internus  of  the  opposite  side  is 
characteristic  of  pontine  lesion,  is  uncertain. 


NOTICES   OF   BOOKS.  91 

Double  motor  paralysis  of  the  limbs  is  not  common.  Con- 
tractures in  paralysed  limbs  often  occur  with  stationary  lesions, 
but  not  epileptiform  convulsions.  Occasionally  ataxic  symp- 
toms have  been  observed. 

Affections  of  sensibility  also  occur,  either  in  the  form  of 
anaesthesia  or  hyperesthesia  in  the  paralysed  parts.  There 
may  be  facial  anaesthesia  on  one  side  and  anaesthesia  of  the 
limbs  on  the  opposite. 

The  symptoms  produced  by  tumours  are  very  variable  and 
difficult  to  distinguish  from  affections  of  the  basis  cranii. 
Some  tumours  remain  latent ;  others  cause  alternate  paralyses, 
or  affections  of  cranial  nerves,  or  disturbances  of  equilibrium. 

The  various  facts  here  indicated  are  generalised  in  the 
diagnostic  propositions  at  the  end  of  the  chapter,  which  is  one 
deserving  the  highest  praise,  and  which  with  its  elaborate 
resume  and  digest  of  cases  will  be  of  signal  use  to  all  neu- 
rologists. 

The  diagnosis  of  affections  of  the  crura  cerebri  rests  on  the 
occurrence  of  paralysis  of  the  oculo-motor  on  the  side  of  lesion, 
and  of  the  extremities  on  the  opposite — the  best  marked 
instance  of  which  is  Weber's  well-known  and  much-quoted 
case.  Such  a  form  of  alternate  paralysis  can  only  occur  with 
a  lesion  at  the  base  of  the  brain.  The  situation  in  the  crus  is 
to  be  determined  mainly  by  the  mode  of  onset.  If  it  occur 
suddenly,  the  crus  is  indicated — not  otherwise. 

Occasionally  from  tumours  both  third  nerves  may  be  im- 
plicated. 

Lesions  confined  to  the  corpora  quadrigemina  in  the  form  of 
haemorrhage  and  softening  do  not  exist.  Hence  conclusions 
as  to  the  special  effects  of  lesion  of  the  corpora  quadrigemina 
have  to  be  founded  almost  entirely  on  tumours,  affecting  these 
ganglia  in  whole  or  in  part,  and  for  this  reason  very  un- 
certain. All  the  published  cases  are  considered  in  detail,  and 
the  following  conclusions  are  based  on  them.  Lesions  of  the 
anterior  tubercles  are  almost  always,  if  not  always,  associated 
with  blindness.  We  may  perhaps  diagnose  a  lesion  here,  if  we 
have  along  with  the  general  indications  of  a  cerebral  affection 
sudden  amaurosis  with  immobility  of  the  pupils,  without  any 
abnormal  ophthalmoscopic  appearances.     In  cases  of  lesion  of 


92  CRITICAL  DIGESTS  AND 

the  posterior  pair  we  may  have  affection  of  the  oculo-motor 
nerves.  This,  however,  is  dubious.  The  character  of  the 
affection  is  peculiar.  Thus  a  bilateral  affection  of  symmetri- 
cally functioning  branches,  such  as  double  ptosis  or  double 
impairment  of  certain  ocular  movements,  points  to  the  corpora 
quadrigemina,  especially  if  no  alternate  paralysis  of  the  ex- 
tremities exists.  This  bilateral  affection  may  result  from 
unilateral  lesion.  In  connection  also  with  lesions  of  the  pos- 
terior tubercles,  disorders  of  co-ordination,  equilibration,  &c, 
have  been  observed,  similar  to  those  of  cerebellar  lesion.  This 
subject,  however,  requires  further  investigation. 

Lesions  of  the  optic  thalami  are  treated  at  considerable 
length,  as  the  obscurities  and  uncertainties  surrounding  the 
question  require.  According  to  the  general  plan  followed, 
recent  haemorrhages  and  softenings,  stationary  lesions  and 
tumours  are  successively  discussed. 

Haemorrhages  confined  to  the  optic  thalami,  and  not  also 
implicating  the  corpora  striata,  are  much  less  frequent  than 
generally  stated  to  be  the  case.  There  are  no  symptoms  which 
enable  us  to  diagnose  with  certainty  a  haemorrhage  into  the 
optic  thalami  as  such,  at  least  at  the  beginning.  The  occur- 
rence of  tonic  or  clonic  spastic  phenomena,  on  which  great 
reliance  is  placed  by  many  observers,  is  not  constant,  nor  are 
they  pathognomonic  of  lesions  of  the  optic  thalami,  as  they 
occur  also  with  haemorrhages  in  the  centrum  ovale,  cortex,  pons, 
and  crus  cerebri.  The  symptoms  met  with  in  connection  with 
chronic  lesions  are  grouped  under  different  heads,  and  illus- 
trated by  reported  cases.  (1)  Some  lesions,  single  or  double, 
may  be  entirely  latent ;  (2)  in  others  then  we  have  anaesthesia 
of  the  opposite  side,  without  motor  paralysis ;  (3)  in  a  third 
group  we  have  hemiplegia  without  affection  of  sensibility  ; 
(4)  in  a  fourth  we  have  hemichorea  or  athetosis,  without  loss 
of  sensibility  or  motor  paralysis ;  and  in  a  fifth  we  have  affec- 
tions of  vision.  The  symptoms,  therefore,  are  exceedingly 
complex  and  contradictory,  and  the  question  is  in  how  far  the 
optic  thalamus  as  such  is  related  to  the  symptoms  described. 

It  used  to  be  taught  by  Saucerotte,  and  more  recently  advo- 
cated again  by  Lussana  and  Lemoigne,  that  the  optic  tha- 
lamus was   more  especially  related  to   the   upper  extremity. 


NOTICES   OF   BOOKS.  93 

This,  however,  Nothnagel  repudiates.  He  reiterates  his  view 
formerly  expressed,  that  lesions  accurately  limited  to  the 
optic  thalamus  occasion  no  motor  paralysis  whatever. 

Motor  paralysis,  if  it  does  occur  in  connection  with  lesion  of 
the  optic  thalamus,  occurs  m6st  frequently  when  the  lesion  is 
in  the  middle  third,  and  is  explicable  by  implication  of  the 
internal  capsule.  Athetosis  and  post-hemiplegic  chorea  are, 
as  is  well  known,  ascribed  by  Charcot  to  lesion  of  the  posterior 
part  of  the  internal  capsule,  but  Nothnagel  is  not  satisfied 
that  the  optic  thalamus  is  not  also  concerned  in  the  causation. 
As  to  affections  of  cutaneous  sensibility,  he  does  not  think 
they  are  related  to  lesion  of  the  optic  thalamus  as  such,  but 
the  question  is  not  altogether  definitively  settled. 

With  respect  to  Crichton-Browne's  view  that  lesions  of  the 
optic  thalami  are  associated  with  abolition  of  reflex  excita- 
bility, our  author  does  not  think  it  has  been  conclusively 
established,  but  he  is  disposed  to  accept  it  as  probable. 

The  relation  of  the  optic  thalami  to  "  psycho-reflex  "  move- 
ments is  considered.  In  those  cases  where  there  is  paralysis 
of  volitional  facial  movements  while  the  emotional  continue, 
Nothnagel  thinks  the  optic  thalami  and  their  cortical  connec- 
tions must  be  intact;  while  paralysis  of  the  emotional  with 
retention  of  the  volitional  in  all  probability  will  indicate  lesion 
of  these  parts.  This  question,  however,  is  one  requiring  further 
investigation.  As  to  the  relation  of  the  optic  thalamus,  if 
any,  to  the  muscular  sense,  we  know  nothing  as  yet  at  all 
definite. 

The  question  as  to  the  relation  of  the  optic  thalamus  to 
vision  depends  mainly  on  two  reported  cases,  Kemy's  and 
Hughlings-Jackson's.  In  the  former  it  is  doubtful  whether 
there  was  crossed  amblyopia  or  bilateral  hemiopia ;  in  the 
latter  hemiopia  was  distinctly  made  out.  Nothnagel,  how- 
ever, expresses  considerable  doubt  as  to  whether  the  hemiopia 
can  be  regarded  as  dependent  on  the  optic  thalamus  lesion, 
inasmuch  as  the  same  may  result  from  lesion  of  the  optic 
tract,  and  also  from  lesion  of  the  occipital  lobe — a  question 
discussed  below. 

Vaso-motor  disturbances  are  not  specially  related  to  optic 
thalamus  lesions. 


94  CEITICAL   DIGESTS  AND 

Our  author  would — but  with  reserve — in  diagnosing  a  lesion 
of  the  optic  thalamus  lay  special  stress  on  affection  of  vision 
in  connection  with  lesion  of  the  posterior  part,  on  the  occur- 
rence of  hemichorea,  athetosis  or  tremor,  abolition  of  reflex 
excitability,  and  possibly  of  the  muscular  sense. 

Lesions  of  the  corpora  striata  are  also  discussed  very  fully, 
and  on  a  consideration  of  the  clinical  facts  he  comes  to  the 
following  conclusions. 

Chronic  lesions  of  the  corpus  striatum  may  be  accompanied 
by  motor,  sensory  and  motor,  and  vaso-motor  paralysis  on  the 
opposite  side.  Unless  the  lesion  is  very  small  the  motor  para- 
lysis is  a  constant  symptom.  The  hemiplegia  may  disappear 
if  only  the  nucleus-caudatus  or  nucleus-lenticularis  is  affected. 
In  cases  of  persistent  paralysis — which  occurs  when  the  internal 
capsule  is  injured — secondary  contracture  frequently  sets  in. 
The  motor  paralysis  usually  affects  both  extremities,  the  lower 
facial  region,  and  also  to  some  extent  the  thoracic  and  trunk 
muscles.  The  hypoglossus  is  either  not  affected,  or  only  tem- 
porarily, very  seldom  permanently.  In  rare  cases  only  the 
extremities,  or  the  facial  movements  alone  are  affected.  It  is 
impossible  to  distinguish  between  lesion  of  the  nucleus  cau- 
datus  and  nucleus  lenticularis.  Motor  paralysis  is  the  only 
symptom  where  the  lesion  is  confined  to  the  anterior  part  of 
the  corpus  striatum,  or  the  region  supplied  by  the  lenticulo- 
striate  arteries.  In  some  cases  hemianaesthesia  accompanies 
the  hemiplegia.  This  heniiansesthesia  is  characterised  by  the 
implication  of  the  special  senses  along  with  cutaneous  sensi- 
bility on  the  side  opposite  the  lesion ;  but  the  hemianesthesia 
may  be  confined  to  cutaneous  sensibility  alone.  Usually 
hemianaesthesia  and  hemiplegia  co-exist.  Only  exceptionally 
does  the  latter  disappear,  leaving  the  anaesthesia.  The  exist- 
ence of  hemianaesthesia  points  to  lesion  of  the  posterior  part 
of  the  internal  capsule.  The  lesion  is  also  frequently  accom- 
panied by  vaso-motor  disturbances  on  the  paralysed  side. 

Hemichorea  often  occurs  along  with  anaesthesia,  but  its 
relation  if  any  to  the  corpus  striatum  is  doubtful. 

Centrum  Ovale. — In  considering  and  localising  lesions  of  the 
centrum  ovale  Nothnagel  arrives  at  essentially  the  same  con- 
clusions as  Pitres  (Lesions  du  Centre  Ovale).     He,  however, 


NOTICES  OF   BOOKS.  95 

suggests   some  modifications  of  his  "  sections "  and  nomen- 
clature— not,  however,  of  much  importance. 

Lesions  are  latent  when  they  occupy  the  occipital,  sphenoi- 
dal, and  frontal  (anterior  and  middle)  sections.  Tumours  in 
these  regions  may  also  remain  latent  as  regards  special 
symptoms,  only  those  characteristic  of  intracranial  tumours 
in  general  existing. 

Even  if  special  symptoms  exist  in  connection  with  lesions  of 
the  centrum  ovale,  it  is  not  possible  to  fix  the  seat  of  lesion 
with  certainty,  as  the  same  symptoms  may  occur  from  cortical 
lesions,  or  even  from  lesions  of  the  corpus  striatum.  The 
special  symptoms,  which  occur  only  with  lesions  in  the  fronto- 
parietal region,  are  either  general  hemiplegia,  or  monoplegia, 
as  in  cortical  lesions.  Our  author  considers  it  doubtful  if 
convulsive  spasms  occur  when  the  lesion  is  strictly  confined 
to  the  centrum  ovale,  and  does  not  implicate  the  cortex ;  but 
early  rigidity  may  occur,  as  argued  by  Pitres,  from  irritation 
of  the  cortico-striate  medullary  fibres.  We  have  no  sufficient 
material  for  forming  any  conclusions  as  to  the  relation  of 
lesions  of  the  centrum  ovale  to  trophic  or  vaso-motor  dis- 
turbances. Aphasia  may  occur  in  connection  with  lesions  in 
the  medullary  fasciculi  of  the  third  left  frontal  convolu- 
tion. 

Cortex  Cerebri. — In  treating  of  lesions  of  the  cortex  our 
author  again  expressly  states  that  he  founds  his  conclusions 
on  clinical  facts  alone — entirely  abstracting  from  physio- 
logical considerations.  His  conclusions  as  regards  affec- 
tions of  motility  agree  in  all  essential  respects  with  those  of 
Charcot  and  other  writers  on  cerebral  localisation.  That  is, 
that  in  lesions  strictly  cortical  affecting  the  anterior  and 
posterior  central  convolutions,  and  paracentral  lobule,  we  have 
either  hemiplegia,  or  monoplegia,  according  to  the  position 
and  extent  of  the  lesion  in  these  regions.  As  regards  the 
exact  locality  of  the  lesions  causing  the  different  forms  of 
monoplegia,  there  is  little  or  nothing  requiring  special  mention 
in  connection  with  the  literature  of  this  subject. 

The  cortical  position  of  the  lesion  is  to  be  diagnosed  not  so 
much  from  the  paralysis  itself  but  from  the  accessory  phe- 
nomena, such  as  local  or  generalised  irritative  phenomena,  &c. 


96  CEITICAL   DIGESTS   AND 

Hemiplegia  with  aphasia  points  to  cortical  origin ;  also 
hemiplegia  associated  with  ptosis. 

Nothnagel,  however,  does  not  accept  the  view  advocated  by 
Landouzy  that  ptosis  indicates  lesion  of  the  parietal  lobule 
(angular  gyrus).  In  reviewing  the  cases  which  have  been 
brought  forward  as  destructive  lesions  of  the  motor  zones 
without  paralysis,  he  holds  that  there  is  not  a  single  un- 
equivocal case  on  record.  Either  the  position  of  the  lesion  is 
not  accurately  given,  or  the  nature  of  the  lesion  is  such  as  not 
necessarily  to  destroy  or  entirely  abolish  functional  activity. 
He  justly  ridicules  a  collection  of  cases  by  Lussana  and 
Lemoigne  as  of  no  scientific  value  whatever. 

Before  passing  from  Nothnagel's  consideration  of  the  motor 
affections  in  connection  with  cortical  lesions,  we  may  observe 
that  paralysis  of  the  tongue  from  cerebral  lesions  is  spoken  of 
as  paralysis  of  the  hypoglossus,  and  similarly  in  regard  to 
other  monoplegias.  By  the  term  paralysis  of  the  hypoglossus 
a  peripheral  paralysis  is  apt  to  be  suggested,  though  not 
intended.  It  would  be  well  to  avoid  terms  which  are  likely  to 
create  confusion  and  misconception. 

The  affections  of  sensibility  which  our  author  attempts  to 
connect  with  lesions  in  certain  parts  of  the  cortex  are  affections 
of  the  muscular  sense,  and  affections  of  sight — particularly 
hemiopia.  The  evidence  adduced  on  these  heads,  however,  is 
not  of  a  very  satisfactory  character. 

He  admits  that  affections  of  cutaneous  sensibility  have  no 
relation  to  cortical  lesions,  and  yet  on  the  strength  of  two  or 
three  cases,  complicated  either  with  cutaneous  paresthesia 
or  anaesthesia,  and  not  one  of  which  can  be  regarded  as 
admissible  in  evidence,  the  lesions  being  either  multiple,  or 
extending  deeply  into  the  brain-substance,  he  ventures  to 
conclude  that  probably  affections  of  muscular  sense  are  due 
to  lesion  in  the  parietal  region  of  the  cortex,  a  region  near, 
but  not  identical  with,  the  motor  regions — a  region,  likewise, 
in  which  lesions  are  frequently  if  not  generally  found  to  be 
latent. 

In  formulating  such  conclusions  our  author  seems  to  violate 
the  principles  by  which  he  professes  to  be  guided  in  reading 
clinical  facts. 


NOTICES   OF   BOOKS.  97 

The  very  cases  here  related  may  be  interpreted  much  more 
in  accordance  with  established  clinical  facts,  by  lesion  direct 
or  indirect  of  the  posterior  part  of  the  internal  capsule  and  its 
neighbourhood.  „ 

Our  author  refers  to  two  distinct  affections  of  sight  in 
connection  with  cortical  lesions,  (1)  double  hemiopia,  (2) 
crossed  amblyopia. 

He  attempts  to  bring  hemiopia  in  relation  with  lesion  of  the 
occipital  lobe — the  retina  being  affected  on  the  side  of  the 
lesion.  That  lesions  of  the  occipital  lobes  may  be  altogether 
latent  is  also  admitted. 

The  cases  on  which  the  relation  between  hemiopia  and  lesion 
of  the  occipital  lobe  is  founded  are  far  from  satisfactory.  In 
Pooley's  case  there  was  also  a  lesion  in  the  optic  thalamus ;  in 
Hirschberg's  there  was  a  tumour  reaching  to  the  optic 
thalamus;  Wernicke's  was  a  case  of  multiple  lesion,  both 
cortical  and  medullary ;  in  Baumgarten's  there  was  also 
lesion  of  the  optic  thalamus ;  and  Nothnagel's  own  case  was 
one  of  diffuse  and  multiple  lesion  in  both  hemispheres. 

On  material  such  as  this  it  is  surely  hazardous  to  found 
conclusions. 

Moreover,  when  we  consider  that  it  has  been  clearly  shown 
that  hemiopia  occurs  from  lesion  of  the  optic  tract,  and  from 
lesion  of  the  optic  thalamus  posteriorly,  we  require  very 
stringent  evidence  that  these  parts  were  free  from  implication, 
directly  or  indirectly,  before  we  can  admit  any  causal  relation 
between  occipital  lesion  and  hemiopia  as  being  made  out.  In 
a  case  recently  brought  before  the  Soc.  Med.  of  Geneva  by 
J.  L.  Prevost,  in  which  hemiopia  was  very  definitely  deter- 
mined, there  was  extensive  occipital  lesion,  but  also  lesion 
of  the  posterior  part  of  the  optic  thalamus  and  external 
geniculate  body. 

Though  Nothnagel  seems  to  be  very  doubtful  of  his  own 
conclusions  in  his  analysis  of  the  facts,  he  is  not  so  careful 
elsewhere,  and  one  might  be  led  to  consider  the  proposition 
established,  which  at  present  at  least  it  is  not.  While  he  with 
some  degree  of  confidence  connects  hemiopia  with  lesions  of 
the  occipital  lobe,  he  does  not  offer  any  suggestion  as  to  the 
locality  of  the  lesion  which  produces  crossed  blindness.     This 

vol.  in.  h 


98  CRITICAL   DIGESTS  AND 

symptom  has  been  chiefly  observed  by  Furstner  in  general 
paralytics. 

Nothnagel  thinks  that  the  connection  between  "word- 
deafness  "  and  lesion  of  the  superior  temporo-sphenoidal  con- 
volution fairly  well-established.  As  regards  aphasia,  his  con- 
clusions are  essentially  those  of  Kussmaul.  We  have  no 
definite  clinical  facts  enabling  us  to  connect  affections  of  smell 
and  taste  with  cortical  lesions.  Similarly  as  regards  trophic 
and  vaso-motor  disturbances.  Psychical  disturbances  are  as 
yet  beyond  localisation. 

As  to  the  effects  of  lesions  limited  to  the  comu  ammonis  we 
at  present  know  nothing.  The  reported  facts  as  to  the  occur- 
rence of  sclerosis  and  atrophy  of  the  hippocampus  in  epileptics 
are  briefly  reviewed,  but  no  causal  relationship  is  considered 
to  be  made  out.  There  are  likewise  no  symptoms  enabling  us 
to  diagnose  lesion  in  the  elaustrum  or  external  capsule. 

As  to  the  ventricles,  there  are  no  definite  symptoms  indicating 
effusion  in  one  or  other  as  distinct  from  effusions  elsewhere. 
A  diagnosis  of  lesion  of  the  fourth  ventricle  may  be  made  if 
after  an  injury  to  the  head  there  should  appear  diabetes  mel- 
litus  or  insipidus,  with  general  cerebral  symptoms  such  as 
headache,  vertigo,  vomiting,  and  possibly  also  slowing  of  the 
pulse  and  mental  hebetude.  The  diagnosis  will  of  course  be 
rendered  more  precise  by  the  occurrence  of  symptoms  special 
to  lesions  of  the  pons  and,  medulla  already  described. 

Affections  of  the  basis  cranii  are  very  variable  and  complex. 
Apart  from  general  indications  of  intracranial  disease,  the 
diagnosis  must  be  founded  chiefly  on  the  implication — destruc- 
tive or  irritative — of  the  cranial  nerves,  unilaterally  or  bilate- 
rally, according  to  the  position  of  the  lesion  in  the  anterior, 
middle,  or  posterior  fossa ;  together  with  indications  of  affection 
of  the  cerebro-spinal  tracts. 

Lesions  confined  to  the  anterior  fossa  implicate  the  olfac- 
tory, and  also  the  optic  if  they  extend  backwards. 

In  the  middle  fossa  the  optic,  third,  fourth,  and  sixth  cranial 
nerves  are  specially  liable,  and  also  the  olfactory  if  the  lesion 
extends  forwards.  The  facial  can  only  be  affected  if  the 
lesion  extends  into  the  hiatus  of  the  aqueduct  of  Fallopius. 

Lesions  in  the  posterior  fossa  may  affect  the  fourth,  sixth, 


NOTICES   OF   BOOKS.  99 

and  seventh  (auditory  and  facial),  the  eighth  and  ninth.  The 
third  may  also  be  implicated  if  the  lesion  extends  forwards 
towards  the  middle  fossa.  With  lesions  of  the  posterior  fossa 
also  disorders  of  co-ordination  .specially  occur. 

Lesions  of  the  pituitary  gland  cannot  be  distinguished  from 
other  affections  of  the  middle  fossa.  Nor  can  aneurism  of  the 
hasilar  artery  be  made  out  with  certainty  or  distinguished 
from  lesions  of  the  pons  from  other  causes. 

At  the  end  of  the  work  there  is  an  "  Ueberblick  uber  die 
Herdsymptome,"  which  is  a  kind  of  catalogue  raisonne  of  the 
various  facts  detailed  in  the  body  of  the  work.  In  this  there 
is  a  tendency  to  speak  somewhat  more  positively  than  the 
facts  and  considerations  in  the  previous  part  of  the  work 
justify.  But  though  exceptions  may  be  taken  to  not  a  few 
of  the  propositions  stated  in  this  book,  it  is  without  doubt 
a  splendid  contribution  to  the  literature  of  cerebral  disease, 
and  will  take  its  place  as  a  standard  work  of  reference  among 
all  who  have  to  deal  with  diseases  of  the  nervous  system. 

David  Ferrier. 


The  Crayfish.  An  Introduction  to  the  Study  of  Zoology.  By 
T.  H.  Huxley,  F.K.S.  C.  Kegan  Paul,  1880.  Interna- 
tional Scientific  Series  XXVIII. 

The  publication  of  this  carefully  prepared  and  admirably 
illustrated  volume  should  be  a  subject  of  congratulation  to  a 
large  number  of  different  kinds  of  readers.  It  will  supply  a 
need  which  the  higher  class  of  so-called  general  readers  have 
often  felt  ;*  an  exposition  of  the  current  theories  of  morphology 
and  zoology,  so  illustrated  by  a  reference  to  concrete  facts  as 
to  enable  the  reader  to  pass  his  own  judgment  on  the  character 
of  the  explanations  offered ;  in  some  such  category  as  this  we 
find,  too,  the  medical  practitioner  whose  knowledge  of  com- 
parative anatomy  has  grown  somewhat  hazy,  although  he  still 

1  A  class  which  may,  in  Mr.  Mark  Pattison's  words,  be  said  to  have  for  their 
aim  "to  improve  faculty,  not  to  acquire  knowledge"  (see  his  just  published 
'  Life  of  Milton,'  p.  210). 

H    2 


100  CRITICAL  DIGESTS   AND 

retains  an  affection  for  the  science  which  throws  so  much 
light  over  the  organism  with  which  it  is  his  especial  duty  to 
deal.  The  serious  student,  commencing  morphology  and 
acquainted  with  the  first  elements  of  dissection,  will  find  that 
for  him  its  chief  value  lies  in  the  way  in  which  zoological  facts 
and  anatomical  characters  are  used  to  illustrate  the  processes 
by  which  modern  naturalists  attempt  to  explain  the  phe- 
nomena of  living  creatures.  The  researches  of  Mr.  Ward,  to 
which  it  is  purposed  to  call  especial  attention  later  on,  will 
suggest  that  the  commencing  physiologist,  unknown  to  fame, 
and  prevented,  by  the  ill-directed  activity  of  the  Legislature, 
from  experimenting  on  the  vertebrated  animals,  may  find  in 
this  volume  not  only  many  suggestive  hints  as  to  the  physio- 
logical processes  of  the  crayfish,  but,  further,  that  groundwork 
of  anatomical  details  which  will  equip  him  for  the  work  of 
resolving  some  still  pressing  physiological  problems  by  the  aid 
of  this  quite  sufficiently  complex  organism. 

There  is  no  need  to  say  that  the  book  is  well  written,  the 
style  concise,  the  expositions  clear ;  but  it  is  a  satisfaction  to 
add  that  there  are  no  attempts  at  fine  writing  or  any  humorous 
interpolations,  while  the  woodcuts  are  eloquent  of  the  care 
that  has  been  bestowed  upon  them. 

Commencing  with  an  account  of  the  'Natural  History 
of  the  Common  Crayfish,'  the  author  insists,  at  the  outset,  on 
the  fact  that  "science  is  common  sense  at  its  best;  that  is, 
rigidly  accurate  in  observation,  and  merciless  to  fallacy  in 
logic ;"  this  is  urged  from  several  points  of  view ;  it  is  shown 
how  a  common  knowledge  of  nature  grows  into  physical 
science,  and  how  its  various  stages  of  growth  can  be  daily 
exemplified  from  our  knowledge  of  those  around  us ;  it  is  used 
as  an  argument  for  technical  terms,  and  we  would  recommend 
those,  who  look  upon  science  as  a  mere  matter  of  hard  names, 
to  read  what  comes  before  and  what  succeeds  the  following 
sentence : 

"Existing  signs  may  be  combined  in  loose  and  cumbrous 
periphrases;  or  new  signs,  having  a  well-understood  and 
definite  signification,  may  be  invented.  The  practice  of 
sensible  people  shows  the  advantage  of  the  latter  course ;  and 
here,  as  elsewhere,  science  has  simply  followed  and  improved 


NOTICES  OF   BOOKS.  101 

upon  common  sense."  Whatever  be  the  common  sense  pos- 
sessed by  those  to  whom  this  quotation  is  addressed,  they  must 
be  careful  lest  they  are  not  outstripped  by  the  subject  of  this 
volume ;  we  learn  that  not  only  are  crayfishes  intolerant  of 
great  heat,  but  that  they  affect  those  parts  of  a  river  which 
run  north  or  south,  because  they  yield  more  shade  from  the 
noonday  sun  than  those  parts  which  run  east  and  west.  In  the 
winter  they  form  burrows  in  the  banks,  and  these  burrows  are 
deeper  when  the  waters  are  liable  to  freeze.  It  seems, 
however,  that  from  the  human  point  of  view,  at  any  rate, 
the  crayfish  carries  his  common  sense  a  little  too  far,  perhaps 
because  he  cannot  convert  it  into  science ;  "  crayfishes  are 
guilty  of  cannibalism  in  its  worst  forms ;  and  a  French 
observer  pathetically  remarks  that  the  males  *  meconnaissent 
les  plus  saints  devoirs ; '  and,  not  content  with  mutilating  or 
killing  their  spouses,  after  the  fashion  of  animals  of  higher 
moral  pretensions,  they  descend  to  the  lowest  depths  of  utili- 
tarian turpitude,  and  finish  by  eating  them." 

To  come  to  the  nervous  system  itself.  As  is  well  known,  all 
animals  which  are  known  as  invertebrata  are  distinguished 
from  those  which  are  called  vertebrata  (here,  of  course,  in- 
cluding, as  a  degenerated  branch,  the  tunicata)  by  the  obvious 
fact  that  their  central  nervous  system  is  "  ventral "  and  not 
"dorsal,"  or,  in  other  words,  that  they  are  " neuropodous "  and 
not  "  hsemapodous  "  ;  the  "  ventral  ganglionic  chain  "  is  in 
animals  which,  like  the  crayfish,  are  made  up  of  a  number  of 
successive  segments  arranged  typically  in  the  same  metameric 
fashion  as  the  appendages  and  some  other  of  the  organs  of  the 
body ;  it  is,  however,  rare  to  find  in  the  adult  that  the  masses 
of  ganglionic  matter  retain  their  primitive  disposition ;  some 
of  the  lowlier  Crustacea  would  appear  to  do  so,  but  in  all  the 
higher  forms  there  is  apparent,  especially  in  the  more  anterior 
region,  a  more  or  less  striking  concrescence  of  a  certain 
number  of  ganglionic  masses;  in  a  common  crab  (Carcinus 
mmnas)  this  fusion  is  carried,  for  example,  to  an  extreme,  and 
the  whole  of  the  ganglia  of  the  ventral  cord  are  fused  into  a 
single  mass.  The  crayfish  has  thirteen  distinct  ganglia  to  its 
twenty  segments,  and  of  these  the  first  is  the  brain  or  supra- 
oesophageal  mass;  the  second  or  sub-oesophageal  ganglion  is 


102  CKITICAL   DIGESTS   AND 

apparently  composed  of  five  primitively  distinct  masses,  for  it 
sends  off  nerves  for  five  segments,  while  the  supra-cesophageal 
ganglia  are,  as  in  so  very  many  of  the  forms  allied  to  the 
crayfish  (other  arthropoda),  formed  by  the  fusion  of  three 
others. 

These  ganglia  are  connected  together  by  a  pair  of  commis- 
sural cords  of  varying  length,  while  they  give  off  a  number  of 
fibres  either  to  the  muscles,  or  to  the  organs  of  sense,  or  to  the 
integument  generally ;  and  the  only  important  difference 
between  them  seems  to  lie  in  the  influence  which  the  supra- 
cesophageal  ganglia  have  over  the  rest.  When  these  are  ex- 
tirpated we  find  that,  as  Professor  Huxley  states,  the  creature, 
which,  when  uninjured,  always  attempts  and  ordinarily  suc- 
ceeds in  regaining  its  proper  position  if  it  be  placed  on  its 
back,  is  now  no  longer  able  to  do  so ;  "  its  limbs  are  in 
incessant  motion,  but  they  are  'all  abroad;'  and  if  it  turns 
over  on  one  side,  it  does  not  seem  able  to  steady  itself,  but 
rolls  on  to  its  back  again."  If,  previously  to  the  operation, 
anything  is  put  between  its  own  chelse  it  may  try  to  use  it  as 
a  means  to  turn  over ;  but  after  extirpation  of  the  ganglia  it 
seizes  the  object  and  tries  to  swallow  it ;  if  the  object  is  pulled 
back,  the  chelae  of  the  other  side  are  brought  to  its  aid  and  a 
co-ordination  of  movements  is  strikingly  exhibited ;  this  co- 
ordination may  be  destroyed  by  an  ablation  of  the  thoracic 
ganglia.  These  observations  are  sufficient  to  show  (1)  the 
influence  of  the  cerebral  ganglia,  and  (2)  the  independence  of 
the  succeeding  portion  of  the  nerve-cord.  The  results  attained 
to  by  Mr.  Ward  go  very  much  further,  and  it  will  not  be 
inappropriate  here  to  draw  attention  to  the  results  which,  in 
his  preliminary  notice,  that  observer  has  put  out.1  The  first 
inference  to  which  his  researches  have  led  him  is  this,  there  is 
no  decussation  of  the  longitudinal  fibres  in  the  cray-fish ;  this 
dictum  will  be  found  to  be  supported  by  the  fact  that  division 
of  one  of  the  supra-cesophageal  commissures  is  followed  by  an 
enfeebled  nervous  activity  on  the  same  side ;  not  only  does  it 
happen  that  feeble,  if  any,  responses  are  given  to  "  considerable 

1  'Observations  on  the  Physiology  of  the  Nervous  System  of  the  Crayfish.' 
By  James  Ward,  M.A.,  Proc.  Eoyal  Soc.  March  6,  1879.  (P.K.S.  xxviii.,  p.  379 : 
Communicated  by  Dr.  M.  Foster,  F.R.S.)  See,  also,  '  Journal  of  Physiology,'  II., 
pp.  214-228. 


NOTICES  OF   BOOKS.  103 

excitation  "  of  the  antennae  and  eye-stalks,  but  a  conspicuous 
want  of  symmetry  is  observable  in  the  action  of  the  abdominal 
appendages,  and  "  the  chelae  during  progression  show  a  bias 
towards  the  sound  side." 

The  second  result  is  of  considerable  importance.  It  was 
found  that  the  spontaneous,  or  "  volitional "  activity  of  the 
animal  as  a  whole  depended  upon  the  functional  presence 
of  the  supra-oesophageal  ganglia.  This  was  shown  not  only 
by  the  positive  fact  that  the  animal  exhibits  spontaneity 
and  purpose  so  long  as  one  commissure  remains  intact,  but  by 
the  negative  results  observed  when  both  are  cut.  These  results 
must  be  quoted  in  Mr.  Ward's  own  words : — 

"  When  both  commissures  connecting  the  supra-  with  the 
sub-oesophageal  ganglion  are  divided,  everything  of  the  kind 
[spontaneity  and  purpose]  disappears,  save  that  occasionally 
the  antennae  are  waved  about  in  the  normal  fashion,  though 
much  more  feebly.  The  animal  lies  on  its  back,  the  maxilli- 
pedes,  the  chelae,  and  the  first  three  pairs  of  legs,  for  the  most 
part,  swinging  slowly  to  and  fro  in  perfect  tempo  ;  not,  how- 
ever, as  the  swimmerets  do,  both  sides  synchronously,  but  with 
the  movements  of  one  side  alternating  with  those  of  the  other. 
....  The  feeding  movements  are  a  perfect  mimicry  of  the 
movements  made  when  food  is  actually  seized.  These  last 
appear  to  be  in  all  respects  perfectly  co-ordinated  ;  so  much 
so,  indeed,  that  the  chelate  legs  will  wait  their  turn  to  pass 
their  morsel  to  the  mouth  when  scraps  are  placed  in  all  of 
them  at  once.  But  neither  they,  nor  the  chelae,  nor  the 
posterior  maxillipedes  show  any  selective  power,  even  the 
animal's  own  antennae  being  seized.  The  first  evidence  of 
taste  appears  when  the  food  gets  within  the  gape  of  the  man- 
dibles." When,  in  such  condition  of  its  nervous  centres,  the 
animal  attempts  to  walk  it  is  found  that  after  a  few  slow  and 
tottering  steps  it  rolls  helplessly  on  to  its  back.  The  results 
just  now  detailed  are  also  sufficient  to  show  that  the  supra- 
cesophageal  ganglion  presides  over  the  inhibition  of  the 
"  aimless  and  wasteful  mechanical  activity  of  the  lower 
centres,"  and  over  the  power  to  maintain  equilibrium. 

When  the  supra-oesophageal  ganglion  has  been  put  aside, 
the  next  question  is  as  to  the  special  influence  which  the  sub- 


104  CRITICAL   DIGESTS   AND 

oesophageal  ganglion  may  possess.  This,  again,  may  be  looked 
at  from  what  has  been  called  the  positive  and  the  negative 
aspect.  As  to  the  former,  it  is,  as  Mr.  Ward  points  out,  ob- 
vious that  "the  sub-cesophageal  ganglion  is  the  source  of  a 
considerable  amount  of  motor  energy,"  for  not  only  is  there, 
as  already  detailed,  an  amount  of  movement  still  possible 
when  these  centres  are  still  connected  with  the  posterior 
portions  of  the  cord,  but  it  was  found  on  experiment  that  the 
posterior  maxillipedes  still  exhibit  sufficient  energy  to  raise 
the  creature  several  times,  and  preening  movements  of  the 
hinder  limbs  are  well  exhibited ;  better,  indeed,  than  before. 
On  the  other,  or  negative  side,  we  find  such  evidence  as  this : 
"  The  chelae  sprawl  helplessly  on  either  side,  and  the  legs  are 
for  the  most  part  doubled  up  under  the  body."  The  chelae, 
too,  are  not  always  successful  in  passing  food  to  the  mouth, 
and  when  they  do  get  it  there  they  still  do  not  let  it  go.  The 
sub-oesophageal  ganglion  would  seem,  therefore,  to  be  the 
centre  for  the  feeding  movements. 

Our  quotations  from  Mr.  Ward  are  even  already  not  incon- 
siderable ;  but  it  is  impossible  to  put  into  less  concise  lan- 
guage the  differences  between  the  crayfish  and  the  frog  as 
enunciated  in  his  next  paragraph  : — 

"  There  is  much  less  solidarity,  a  much  less  perfect  consensus 
among  the  nervous  centres  in  the  crayfish  than  in  animals 
higher  in  the  scale.  The  brainless  frog,  e.g.,  is  motionless 
except  when  stimulated,  and  even  then  does  nothing  to  sug- 
gest that  its  members  have  a  life  on  their  own  account; 
whereas  the  limbs  of  a  crayfish,  deprived  of  its  first  two 
ganglia,  are  almost  incessantly  preening,  and  when  feeding 
movements  are  started  the  chelate  legs  rob  and  play  at  cross 
purposes  with  each  other  as  well  as  four  distinct  individuals 
could  do." 

Here  we  must  leave  Mr.  Ward,  but  we  cannot  do  so  without 
expressing  a  sincere  hope  that  a  full  account  of  his  important 
researches  will  soon  be  published,1  nor  without  returning  again 
to  the  point  at  which  we  hinted  at  the  commencement  that 
other  physiologists  will  concern  themselves  with  a  creature 

1  A  notice  by  M.  Yung  in  the  '  Comptes  Rendus,'  Ixxxviii.  p.  347,  affords  an 
independent  support  to  several  of  Mr.  Ward's  conclusions. 


NOTICES   OF  BOOKS.  105 

in  which  the  phenomena  of  inhibition  seem  to  be  particularly 
easily  accessible. 

The  general  reader  already  referred  to  will  probably  be  a 
little  astonished  at  the  heading  of  page  89.  The  ordinary 
human  being  has,  for  no  reason  at  all,  either  positive  or  nega- 
tive that  we  have  ever  been  able  to  discover,  except  from  the 
strength  of  his  position  as  a  lord  of  creation,  assumed  to  him- 
self the  especial  and  peculiar  possession  of  a  mind ;  the  term, 
therefore,  "  the  crayfish  mind "  will,  no  doubt,  excite  his 
antipathies,  and  the  fact  that  the  question  of  the  crayfish 
having  or  not  having  a  mind  is  left  an  open  question  will 
hardly  console  him.  The  various  steps  of  a  reasoning  process, 
and  the  stage  at  which  this  becomes  logical  are,  nevertheless, 
most  admirably  stated  in  a  few  short  paragraphs  by  Professor 
Huxley,  and  the  whole  question  summed  up  by  pointing  out 
that  we  could  only  have  a  "  positive  assurance  "  that  the  cray- 
fish possesses  consciousness  by  being  a  crayfish  ourselves.  See- 
ing no  expectation  of  this,  the  phenomena  associated  with  the 
activity  of  nerve  and  muscle  are  carefully  explained,  and  form 
the  basis  for  the  important  physiological  lesson  that  so-called 
spontaneous  movements  do  not  really  cause  themselves,  and 
that  what,  at  any  rate,  the  crayfish  "does  at  any  moment 
would  be  as  clearly  intelligible,  if  we  only  knew  all  the  in- 
ternal and  external  conditions  of  the  case,  as  the  striking  of  a 
clock  is  to  any  one  who  understands  clockwork."  1 

Some  points  which  especially  interest  nerve-physiologists 
are,  however,  altogether  passed  over.  This,  no  doubt,  is  com- 
pletely in  accordance  with  the  aim  which  this  experienced 
expositor  of  scientific  facts  had  definitely  set  before  himself; 
but  it  should  be  pointed  out  that,  so  far  as  analogy,  at  any 
rate,  is  concerned,  it  is  a  considerable  advantage  to  the  student 
of  the  vertebrata  to  know  that  there  is  a  visceral  system  of 
nerves  in  the  non-vertebrated  animals.  The  ganglia  on  the 
dorsal  surface  of  the  stomach,  and  the  two  nerves  given  off 
from  the  oesophageal  commissures,  to  say  nothing  of  the  plexus 

1  A  sentence  of  Mr.  Pattison's  ('  Milton,'  p.  174)  is  well  worthy  of  being  quoted 
in  this  connection :  "  That  in  selecting  a  Scriptural  subject  he  was  not  in  fact 
exercising  any  choice,  but  was  determined  by  his  circumstances,  is  only  what  must 
be  said  of  all  choosing." 


106  CKITICAL   DIGESTS   AND 

which  is  reported  to  be  connected  with  the  last  abdominal 
ganglion,  are  so  far  of  importance  that  they  remove  a  difficulty 
from  the  student,  who  so  frequently  learns  nothing  of  a  sympa- 
thetic system  till  he  comes  into  contact  with  vertebrated 
animals,  and  they  seem  from  their  origin  to  have  a  still  higher 
significance,  if  the  view  to  which  Mr.  Balfour  is  evidently  in- 
clined shall  be  justified  by  further  investigations ;  the  view, 
namely,  that  intestinal  branches  are  developed  on  the  main 
nerve  stems  of  the  thoracic  and  abdominal  portions  of  the 
central  nervous  system,  and  that  the  ganglia  developed  on 
these  become  connected  by  a  longitudinal  commissure.1 

This,  of  course,  would  be  by  the  way  in  any  other  journal 
than  '  Brain.'  Having  said  this,  we  may,  however,  draw 
attention  to  one  or  two  interesting  points  in  nerve-muscle 
physiology  which  have  recently  resulted  from  the  observations 
of  continental  observers  : — 

(1)  When  the  visceral  nerves  passing  off  from  the  commis- 
sural cords  are  directly  excited,  the  movements  of  the  heart 
are  accelerated ;  but  if  the  thoracic  ganglia  (which  commu- 
nicate through  the  supra-cesophageal  ganglion)  are  excited, 
the  heart's  beat  is  retarded  (Yung).  These  first  results  may, 
perhaps,  be  not  unfairly  compared  with  the  influence  of  the 
spinal  accelerator  nerves  in  the  vertebrata. 

(2)  The  tail-muscles  of  the  crayfish  soon  lose  their  power 
of  contraction  when  they  are  rapidly  affected  by  a  number 
of  electric  shocks;  this  is  in  keeping  with  the  fact  that  the 
animal  never  swims  for  long  at  a  time.     (Bichet.) 

(3)  The  muscles  of  the  great  chelae  may  retain  their  con- 
tractility for  as  long  as  four  days  after  separation  from  the 
body;  this,  too,  is  to  be  correlated  with  the  creature's  well- 
known  habits.     (Bichet.) 

(4)  Motor  excitations  pass  more  slowly  along  a  lobster's 
motor  nerve  than  along  that  of  a  frog ;  the  proportion,  per 
second,  being  six  to  twenty-seven  metres.     (Fredericq). 

These,  and  observations  like  these,  which  might  assuredly 
be  multiplied,  are,  from  a  general  point  of  view,  of  deep 
significance  as  illustrating,  just  as  much  as  every  series  of 

1  '  Elasmobranch  Fishes,'  p.  173. 


NOTICES   OF   BOOKS.  107 

investigations  into  morphology  or  physiology  does,  the  deep 
truth  of  Goethe's  words : — 

"  Alle  Gestalten  sind  'aknlich,  doch  gleichet  keine  den  andern." 

And  they  lead  us,  as  they  ought  to  lead  us,  to  examine  with 
respectful  attention  that  theory  of  Evolution  which  Professor 
Huxley  has  done  so  much  to  render  intelligible  as  well  as  to 
demonstrate  as  reasonable. 

Let  us  now  see  how  he  deals  with  what  he  finds  in  the 
crayfish  to  support  the  doctrine  he  has  for  many  years,  through 
good  report  and  ill,  so  manfully  defended.  No  division  of 
the  animal  kingdom  is,  in  this  connection,  more  interesting 
than  the  Crustacea ;  for  from  no  group  have  more  convincing 
argumentations  in  favour  of  the  hypothesis  of  Evolution  been 
drawn.  It  is  now  some  sixteen  years  since  one  of  the  most 
philosophical  and  careful  of  modern  naturalists,  Fritz  Miiller, 
tested  the  views  of  Mr.  Darwin  by  an  especial  reference  to  the 
characters  of  the  Crustacea.  His  essay,  entitled  '  Fur  Darwin,' 
has  been  translated  into  English,  and  is  continually  in  the 
hands  of  those  who  are  interested  in  the  discussion.  As 
compared  with  his  work,  which  to  the  student  is  of  inestimable 
value,  the  contribution  now  offered  by  Professor  Huxley  is 
especially  interesting.  Fritz  Miiller's  work  was  written  in  the 
days  now  fortunately  quite  gone  by,  when  the  attacks  on  the 
great  modern  prophet  of  Evolution  were  of  a  character  which, 
justly  enough,  roused  the  spirit  of  his  disciples.  In  the  dis- 
cussion under  that  aspect  Professor  Huxley  took  his  share ; 
but  in  the  present  volume  we  learn  even  more  convincingly 
than  we  do  from  those  remnants  of  the  past  style  of  "  anti-Dar- 
winian "  criticism  which  now  and  again  appear  in  our  monthly 
magazines  that  the  battle  is  really  over,  and  that,  till  some 
formidable  rival  of  greater  scientific  pretensions  shall  appear, 
the  doctrine  of  Evolution  has  gained  the  day.  In  earlier  times 
Mr.  Huxley  has  known  how  to  use  all  the  weapons  of  scientific 
controversy;  to-day  he  has  found  it  safe  to  lay  aside  all 
armour,  and,  like  his  master  in  this  great  matter,  he  has  dared 
to  expose  even  his  weak  points.  The  discussion,  therefore,  to 
which  he  invites  his  readers  in  the  last  chapter  of  the  volume 
is  not  only  interesting  from  the  way  in  which  difficulties  are 


.108  CRITICAL   DIGESTS   AND 

pointed  out,  but  it  is  valuable  as  affording  evidence  that  in 
matters  more  of  less  hypothetical  the  naturalist  now,  as  in  the 
pre-theoretical  days  which  some  still  profess  to  admire,  has 
no  other  aim  than  that  of  coming,  after  a  time  of  struggle, 
to  some  clearer  apprehension  of  the  real  meaning  of  natural 
phenomena.     It  will  be  right  here  to  quote  our  author : — 

"  The  preceding  discussion  must  rather  be  regarded  as  an 
illustration  of  the  sort  of  argumentation  by  which  a  completely 
satisfactory  theory  of  the  etiology  of  the  crayfish  will  some 
day  be  established,  than  as  sufficing  to  construct  such  a  theory. 
It  must  be  admitted  that  it  does  not  account  for  the  whole  of 
the  positive  facts  which  have  been  ascertained ;  and  that  it 
requires  supplementing,  in  order  to  furnish  even  a  plausible 
explanation  of  various  negative  facts."     (p.  333.) 

The  positive  fact  here  referred  to  is  this.  So  far  as  we 
know  their  characters,  the  East- American  genus  (Camharus), 
in  which  there  is  one  gill  less  than  in  our  crayfish,  has  among 
the  crayfishes  (Astacus)  its  most  closely  allied  form  in  the  cray- 
fish of  the  Amurland  and  of  Japan  ;  while  the  West- American 
forms  are  more  like  the  Ponto-Caspian  form.  No  information 
that  we  have  at  present  of  the  disposition  of  land  and  sea  in 
earlier  geological  epochs  can  yet  explain  this  difficulty.  An 
explanation  of  the  negative  fact  that  crayfishes  are  not 
found  in  certain  regions  is  afforded  us  by  the  idea  that  physical 
obstacles,  of  which  we  have  no  knowledge,  prevented  the 
primitively  marine  ancestor  from  ascending  certain  rivers, 
and  by  the  not  unlikely  suggestion  that  in  certain  rivers  the 
struggle  for  existence  was  more  than  the  invader  could  sustain. 

Our  space  does  not  permit  us  to  follow  the  author  into 
his  account  of  the  fossil  forms  allied  to  the  crayfish;  into 
the  accurate  and  instructive  definition  which  he  gives  of  the 
meaning  of  those  difficult  abstractions,  species  and  genus ;  or 
into  the  history  of  the  development  of  the  special  form  under 
description.  It  will  be  interesting,  however,  to  draw  attention 
to  a  single  example,  which  will,  perhaps,  suffice  to  show  that 
while  embryologists  are  accused  of  weaving  phylogenies  with- 
out end,  they  are,  in  truth,  beset  with  many  difficulties,  the 
partial  resolution  of  which  has  at  least  to  be  accomplished 
before  they  can  attain  to  any  consistent  theory  of  develop- 


NOTICES   OF   BOOKS.  109 

ment.  As  in  many  other  forms,  part  of  the  large  intestine  of 
the  crayfish  and  of  the  lobster  is  formed  by  an  inpushing 
of  the  ectodermal  lining  of  the  body ;  in  the  lobster  it  is 
estimated  that  one-sixth,  and  in  the  crayfish  fifteen-sixteenths, 
of  the  large  intestine  have  their  origin  from  the  outer  layer  of 
the  body.  Differences  such  as  these  are  continually  met  with 
by  the  student  of  development;  they  are  discussed  with  his 
co-workers,  and  it  is  the  grand  results  of  continuous  and 
comparative  labours  which  the  world  is  apt  to  denominate  as 
the  results  of  a  superficial  examination.  The  more  deeply  we 
study  the  animal  world,  the  more  do  we  see  how  apparently 
interminable  these  differences  are.  They  are  hard  enough  to 
cause  at  times  a  feeling  of  despondency,  which  is  only  relieved 
by  a  generous  sympathy ;  this  naturalists  have  often,  though 
hardly  often  enough,  extended  to  their  fellows.  Now,  however, 
we  shall  be  able  to  look  to  a  wider  circle  of  friends  ;  for  no 
intelligent  man  or  woman  will  read  '  The  Crayfish '  without 
having  excited  in  them  a  deeper  interest  than  they  have  yet 
felt  in  the  details  of  animal  organisation,  and  in  the  labours 
of  its  investigators.  From  this  important  point  of  view  the 
work  now  in  hand  is  especially  to  be  welcomed. 

F.  Jeffrey  Bell. 


Pseudo-hypertrophie  Muscular  Paralysis.  A  Clinical  Lecture. 
By  W.  R.  Gowers,  M.D.,  F.E.C.P.  London :  J.  and  A. 
Churchill,  1879. 

This  volume  contains  a  reprint  of  a  lecture  which  appeared 
in  the  Lancet  for  July,  1879,  with  the  addition  of  some  further 
cases  and  details.  It  presents  a  careful  summary  of  our  pre- 
sent knowledge  of  the  clinical  history  and  pathology  of  this 
disease,  to  which  the  author  has  made  valuable  contributions. 
Dr.  Glowers  believes  that  the  change  in  the  muscles  is  a  morbid 
growth  of  connective  tissue  and  fat  in  the  place  of  striped 
muscular  fibre,  and  he  regards  the  condition  as  essentially  a 
perversion  of  development.  The  changes  in  the  spinal  cord 
which  he  and  the  late  Dr.  Lockhart  Clarke  described  were 
slight,  and  he  believes  were  probably  secondary,  as  many  com- 


110  CRITICAL   DIGESTS   AND 

petent  investigators  have  in  other  cases  found  the  cord  normal ; 
where  more  definite  changes — e.  g.  sclerosis  of  lateral  columns, 
atrophy  of  nerve  cells — have  been  found,  he  thinks  there  is 
reason  for  believing  that  some  other  pathological  state  has 
been  confounded  with  this  disease.  In  detailing  the  clinical 
history,  which  is  founded  upon  an  analysis  of  220  cases,  19  of 
which  have  come  under  his  own  observation,  Dr.  Gowers  directs 
attention  to  the  distinctly  hereditary  nature  of  the  affection, 
in  some  instances  six  or  even  eight  members  of  the  same  family 
having  suffered  from  it ;  to  its  tendency  to  affect  males  rather 
than  females,  in  the  proportion  of  6  to  1 ;  to  its  incidence  at 
an  early  age,  usually  before  six  years.  He  describes  the  insi- 
dious manner  in  which  the  disease  reaches  development ;  weak- 
ness of  the  knees,  and  slight  unsteadiness  of  gait  being  often 
for  some  time  the  only  facts  observed,  and  as  often  little 
regarded.  The  enlargement  of  the  muscles,  which  has  been  so 
much  insisted  upon,  may  be  absent,  and  affects  as  a  rule  only 
certain  groups,  notably  those  of  the  calf,  the  infra  spinati, 
deltoids,  and  triceps ;  wasting  of  the  muscles  is  quite  as  com- 
mon, but  affects  different  groups,  especially  the  latissimi  dorsi 
and  pectorals.  But  both  enlarged  and  diminished  muscles 
are  weak,  the  symptoms  of  the  disease  are  the  result  of  this 
weakness,  and  Dr.  Gowers  lays  great  stress  upon  the  efforts 
made  by  the  little  patients  to  raise  themselves  from  the  ground, 
by  grasping  their  knees  with  their  hands  as  a  peculiar  move- 
ment quite  pathognomonic  in  its  significance.  The  treatment 
recommended  is  chiefly  to  improve  the  general  nutrition  by 
arsenic  and  cod-liver  oil,  and  the  muscular  nutrition  by  fara- 
dism  and  moderate  gymnastic  exercise,  aided  by  friction ;  but 
unfortunately  little  can  be  hoped  for,  as  scarcely  an  authenti- 
cated cure  has  been  recorded,  the  patients  becoming  emaciated, 
their  respiratory  muscles  failing,  and  death  finally  resulting 
from  some  acute  or  chronic  pulmonary  disease. 

Dr.  Gowers  has  increased  the  value  of  his  work  by  an 
appendix  giving  notes  referring  to  several  points  of  interest, 
by  a  copious  bibliography,  and  by  a  lithographed  plate  of  the 
microscopical  appearances  of  the  diseased  muscles. 

KOBERT   SAUNDBY,  M.D. 


NOTICES   OF   BOOKS.  Ill 

The  Index  Medicus.  A  Monthly  Classified  Record  of  the  Current 
Medical  Literature  of  the  World.  Compiled  under  the  super- 
vision of  Dr.  John  S.  Billings  and  Dr.  Robert  Fletcher. 
New  York,  F.  Sypfyoldt.     London,  Trubner  &  Co. 

It  is  impossible  to  exaggerate  the  utility  of  this  work,  or  to 
extol  too  highly  the  accurate  industry  of  those  who  are  en- 
gaged in  its  compilation.  Kecording  as  it  does  all  new  publi- 
cations in  medicine,  surgery,  and  the  collateral  branches  of 
science,  and  all  original  communications  in  medical  journals, 
and  transactions  of  medical  societies,  it  arranges  these  in  a 
manner  that  renders  reference  easy,  the  nomenclature  and 
classification  adopted  being  those  of  the  Royal  College  of 
Physicians  of  London,  based  on  Dr.  Farre's  well-known 
system.  It  brings  compendiously  before  the  worker  in  each 
department  all  contemporaneous  research  and  speculation  in 
his  own  field  ;  it  catalogues  all  substantial  additions  to  medical 
knowledge,  and  it  provides  an  inventory  of  the  passing  medical 
fashions  of  the  day.  To  all  medical  practitioners,  teachers, 
and  authors  it  must  prove  useful,  but  to  the  provincial  student, 
who  has  not  access  to  medical  libraries  and  their  array  of 
journals,  it  will  be  especially  valuable,  by  enabling  him  to 
ascertain  what  is  being  done  by  others  in  any  subject  that  he 
may  be  investigating,  thus  guiding  and  stimulating  his  ex- 
plorations, and  saving  him  from  the  repetition  of  twice-told 
tales.  Happily  provincial  students  of  medicine — that  is  to 
say,  those  medical  men  who  are  not  content  with  the  routine 
of  practice  and  money-making,  but  who  feel  the  obligation 
under  which  they  lie  to  promote  the  progress  of  medicine — 
are  daily  increasing  in  number.  The  country  districts  furnish 
much  admirable  work,  and  we  think  that  the  '  Index  Medicus ' 
will  tend  to  improve  the  quality  of  this  work  and  increase  its 
quantity,  while  at  the  same  time  it  diminishes  its  bulk. 

J.  Crichton-Browne,  M.D. 


112  CRITICAL  DIGESTS  AND  NOTICES  OF  BOOKS. 

Shin  Diseases,  including  their  Definition,  Symptoms,  Diagnosis, 
Prognosis,  Morbid  Anatomy  and  Treatment.  A  Manual  for 
Students  and  Practitioners.  By  Malcolm  Morris.  London. 
Smith,  Elder,  &  Co.,  1879.     8vo,  pp.  288. 

The  author  of  this  manual  has  evidently  a  full  and  intimate 
acquaintance  with  the  literature  of  dermatology,  and  with  the 
most  recent  developments  and  appliances  of  cutaneous  medi- 
cine. He  has  produced  a  plain  practical  book,  by  aid  of  which, 
who  so  chooses,  may  train  his  eye  to  the  recognition  of  slight 
but  significant  differences.  The  descriptions  are  neither  too 
vague  nor  over-refined  ;  the  directions  for  treatment  are  clear 
and  succinct.  We  cannot  add,  however,  that  Mr.  Morris  has 
surmounted  the  everlasting  stumbling-block  of  classification, 
his  system  being  compounded  out  of  those  of  Erasmus  Wilson 
and  Hebra,  with  original  touches  here  and  there.  Under  the 
class  Neuroses  we  find  zoster,  cheiro-pempholyx,  pruritus,  and 
dystrophia  cutis,  while  urticaria  takes  place  under  the  Erythe- 
matous Exudationes,  pemphigus  under  the  Vesicular  Exuda- 
tiones,  morphoea  under  the  Hypertrophic  and  alopecia  areata 
under  Diseases  of  the  Hair.  An  appendix  of  formulae  for  baths, 
ointments,  lotions,  &c,  would  much  enhance  the  value  of  the 
book. 

J.  Crtchton-Browne,  M.D. 


Fig.l  ./Bzghb.) 


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Ficj.3 


Fig. 2.  (Left.) 


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0  ~B  e^ju/J^  lx£ns . 


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(MfrriraJ  Cases. 

ARKEST  OF  DEVELOPMENT  IN  THE  LEFT  UPPER 
LIMB,  IN  ASSOCIATION  WITH  AN  EXTREMELY 
SMALL  RIGHT  ASCENDING  PARIETAL  CONVO- 
LUTION. 

BY  H.  CHAKLTON  BASTIAN,  M.D.,  F.R.S., 

and 

V.  HORSLEY, 

A*,<i*tant-Demonstrator  of  Anatomy  in  University  College,  London. 

In  the  number  of  '  Brain  '  for  October  1878,  Dr.  Gowers  has 
published  an  account  of  a  case  in  which  congenital  absence  of 
the  left  hand  co-existed  with  unequal  development  of  the 
ascending  parietal  convolutions,  the  right  being  the  smaller. 
Towards  the  close  of  1879,  a  case,  which  has  since  proved  to-  be 
very  similar,  was  admitted  into  University  College  Hospital, 
under  the  care  of  Dr.  Bastian.  The  following  facts  concerning 
this  case  seem  to  us  worthy  of  being  recorded. 

J.  M.  B.,  aged  26,  a  clerk,  was  admitted  into  the  hospital  on 
October  18th,  1879,  suffering  chiefly  from  mitral  obstruction 
and  regurgitation.  He  got  rapidly  worse  (owing  in  part  to 
rupture  of  one  of  the  chord ob  tendinere  of  the  mitral  valve), 
and  died  rather  suddenly  on  October  30th,  1879. 

Necropsy,.  Oct.  31s/,  1879.  The  body,  on  the  whole,  showed 
slight  muscular  development,  especially  in  and  in  relation  with 
the  left  upper  limb,  both  pectoral  muscles  on  that  side  being 
absent.  Unfortunately,  permission  to  dissect  the  limb  (which 
was  shorter  and  much  slighter  than  that  of  the  right  side)  could 
not  be  obtained,  but  the  arrangement  of  the  bones  in  the  small 
and  abortive  "  hand  "  was  readily  felt  through  the  skin,  and  is 
represented  in  the  accompanying  figure  (H),  copied  from  a  sketch 
made  by  the  physician's  assistant,  Mr.  B.  Pollard.  The  dotted 
lines  show  the  outlines  of  the  bones.  The  position  and  pro- 
portion of  the  metacarpals  bear  a  close  resemblance  to  the 
early  appearances  of  segmentation,  seen  as  slight  ridges  and 
intervening  depressions  in  the  forelimb  of  an  embryo  (man) 

VOL.   III.  I 


114  CLINICAL  CASES. 

about  2  cm.  in  length.  In  the  case  of  Dr.  Gowers,  above  re- 
ferred to,  in  which  one  of  us  had  the  opportunity  of  dissecting 
the  limb,  the  theory  of  intra-uterine  amputation  was  favoured 
by  the  condition  of  the  parts ;  but  in  the  present  instance  the 
appearances  are  strongly  in  favour  of  arrest  of  development. 

The  brain,  on  removal,  was  divided  longitudinally,  and  each 
half  placed  on  its  inner  surface  in  a  2*5  per  cent,  solution  of  bi- 
chromate of  ammonia.  The  membranes  were  at  once  removed 
over  the  ascending  convolutions  on  each  side,  when  a  striking 
difference  appeared  (as  shown  in  figs.  1,  2).  After  24  hours, 
the  middle  three-fifths  of  each  ascending  parietal  convolution 
was  measured  at  seven  equidistant  points  between  the  dots  in 
each  figure,  and  the  following  results  were  obtained : 

Left  A.P.C.      Right  A.P.C. 


1 

14 

1-5 

2      . 

16 

]-5 

8 

1-5 

1-85 

4 

1-4 

1-7 

5 

1*3 

•8 

i; 

19 

10 

7 

1-8 

1-3 

Thus  it  is  seen  that  at  the  points  5  and  6,  the  difference  in 
breadth  was  almost  2  to  1  in  favour  of  the  left  asc.  par. 
conv.,  and  that,  on  the  whole,  there  was  a  difference  of  '2  cm. 
between  the  right  and  left  convolutions.1  There  was  no  such 
striking  asymmetry  in  the  rest  of  the  brain ;  the  basal  ganglia 
and  descending  motor  tracts  in  the  pons  and  medulla  being 
apparently  equal.  A  careful  microscopical  examination  re- 
vealed no  appreciable  difference  in  the  internal  or  minute 
structure  of  the  two  convolutions. 

From- the  above  facts  we  see  that  the  regions  of  the  cortex, 
corresponding  with  the  "  centres  "  "  a,  b,  c,  d  "  of  Dr.  Ferrier,'2 
were  but  slightly  developed  on  the  right  side.  The  actions 
evoked  by  stimulation  of  these  centres  he  gives  as,  "  In- 
dividual and  combined  movements  of  the  fingers  and  wrist, 
ending  in  clenching  of  the  fist."  And  in  this  man  such 
movements  had  certainly  been  for  the  most  part  impossible 
with  the  left  "  hand." 

It  would  seem,  then,  that  we  have  here  another  instance 
tending  to  corroborate  the  view  that  there  is  a  correlation  of 
some  kind  between  the  functional  activities  of  these  regions  of 

1  The  drawings  were  obtained  by  taking  impressions  of  the  sulci  by  means 
of  tinfoil.  The  deepest  portions  of  the  sulci  bung  marked  by  punctures,  the 
tinfoil  was  laid  on  the  paper,  and  the  latter  marked  through  the  holes.  The 
accuiacy  of  the  drawings  was  finally  verified  by  numerous  comparative  measure- 
ments. "  The  actual  breadth  of  the  convolutions  themselves  was  filled  in  from 
the  above  measurements,  and  the  figures  were  then  reduced  one-third. 

2  '  Functions  of  the  Brain,'  pp.  148  and  307. 


CLINICAL  CASES.  115 

the  ascending  parietal  convolution,  and  the  movements  of  the 
opposite  hand  and  fingers — as  indicated  by  the  experimental 
observations  of  Dr.  Ferrier. 

It  seems  something  more  than  can  be  accounted  for  by  mere 
chance  coincidence,  when  precisely  the  regions  of  the  cortex 
indicated  by  him  are  found  to  be  defective  in  bulk  in  two  con- 
secutive cases  of  absence  or  arrest  of  development  of  the  hand. 
Yet  those  who  are  still  a  little  sceptical  will  doubtless  await 
further  coincidences  of  the  same  kind,  and  will  seek  to  learn 
something  definite  as  to  the  degree  of  frequency  with  which  a 
marked  asymmetry  of  the  ascending  parietal  convolutions  of 
the  two  sides  is  to  be  met  with  in  cases  where  no  malformation 
of  one  hand  is  present. 

The  question  of  the  existence  or  not  of  a  correlation  of  this 
kind  is  one  which  does  not  by  any  means  necessarily  associate 
itself  with  the  view  that  the  particular  regions  of  the  cortex 
indicated  contain  "  motor  centres."  A  correlation  may  really 
exist  between  the  activities  of  special  cortical  regions  and  the 
performance  of  particular  movements,  and  yet  the  commonly 
received  explanation  of  such  a  correlation  may  not  be  correct. 

Thus  it  is  possible  to  accept  as  a  fact  the  existence  of  such 
correlations,  and  at  the  same  time  wholly  to  reject  the  view 
that  anything  like  a  "  motor  centre "  is  to  be  found  in  the 
cerebral  cortex. 

A  complex  group  of  ingoing  impressions  follows  or  is  pro- 
duced by  movements  of  the  hands,  as  of  all  other  parts  of  the 
body,  so  that  we  may  be  said  to  have  a  "  sense  of  movement " 
growing  out  of  the  repetition  of  what  one  of  us  has  termed 
kinsesthetic  impressions * — just  as  our  sense  of  sight  is  developed 
from  the  repetition  of  visual  impressions. 

Sensory  impressions  of  both  these  types,  derived  from  move- 
ments, will  subsequently,  when  ideally  revived,  co-operate  as 
factors  in  the  reproduction  of  similar  movements.  The  activity 
of  the  "  kinEesthetic  centres,"  more  especially,  would  thus  be 
closely  related  to  the  reinitiation  of  movements — and  different 
parts  of  such  centres  would  have  to  do  with  the  production  of 
different  kinds  of  movements.  Thus  stimulation  of  certain 
sensory  regions  of  this  type  may  lead  to  the  manifestation  of 
certain  movements,  whilst  destruction  of  the  same  sensory 
regions  may  abolish  the  possibility  of  performing  such  move- 
ments. The  so-called  "  motor-centres "  may,  therefore,  in 
reality,  be  sensory  regions  of  the  kinesthetic  type,  and  these 
cortical  areas  may  in  addition  take  part  in  the  performance  of 
other  cerebral  functions  whose  nature  cannot  be  at  present 
specified. 

1  '  The  Brain  as  an  Organ  of  Mind  '  (1880),  pp.  543  and  522. 

i  2 


116  CLINICAL   CASES. 

The  fact  that  the  small  right  ascending-  parietal  did  not 
differ  in  its  microscopical  characters  from  the  well-developed 
left  ascending  parietal  convolution,  is  not  incompatible  with 
the  existence  of  a  correlation  of  some  kind  between  these 
parts  and  certain  movements  of  the  hand,  whether  their 
activities  be  of  the  sensory  or  of  the  motor  type.  In  such  a 
case  as  we  have  now  brought  forward,  there  Avould  be  no  reason 
to  look  for  atrophied  nerve  cells,  merely  because  certain  move- 
ments have  never  occurred,  but  rather  for  a  numerical  inferiority 
of  nerve  cells  and  a  mere  inferior  bulk  of  convolution  in  re- 
lation with  an  abortive  limb  whose  possible  movements  were 
notably  curtailed.  % 


CASE  OF  NERVE-SPLITTING. 

BY  SURGEON-MAJOR  K.  M'LEOD,  A.M.,  M.D.,   F.C.U., 
Professor  of  Surgery,  Calcutta  Medical  College. 

C.  K.,  ait.  26,  a  spare  East  Indian  youth  of  nervous  tempera- 
ment, consulted  me  on  the  27th  of  December  regarding  a 
wasting  of  the  left  forearm  and  hand,  and  numbness  of  the 
latter,  from  which  he  had  suffered  for  8  years,  and  fur  which  he 
had  been  subjected  to  various  plans  of  treatment,  without  gain- 
ing relief  from  any.  In  the  year  1871  he  began  to  experience 
peculiar  sensations  in  the  little  finger  and  ulnar  side  of  the 
left  hand.  The  parts  gradually  got  numb,  the  muscles  of  the 
hand  wasted,  and  the  fingers  became  permanently  bent.  He 
sought  relief  at  the  Presidency  General  Hospital,  when  it  was 
discovered  that  the  ulnar  nerve  had  undergone  thickening. 
Blisters  were  applied  along  the  course  of  the  nerve,  and  subse- 
quently iodine  and  magnetic  electricity,  but  no  benefit  was 
derived  from  these  energetic  remedies.  An  ■  abscess  formed  in 
1875  above  the  elbow  on  the  inner  side,  which  discharged 
spontaneously,  and  left  a  sinus  which  continued  to  emit  matter 
for  some  time,  and  then  closed  of  itself.  This  sinus  reopened 
in  1879,  without  apparently  any  fresh  accession  of  inflamma- 
tion.    His  condition  when  I  examined  him  was  as  follows : — 

Left  arm  generally  less  muscular  than  the  right ;  circum- 
ference of  left  forearm  1  inch  less  than  right.  Special  wasting 
over  position  of  flexor  carpi  ulnaris.  Hand  very  much  wasted, 
more  particularly  the  short  muscles  of  the  little  finger,  the 
interossei,  and  the  adductor  pollicis.  The  short  muscles  of  the 
thumb  are  smaller  in  bulk  than  on  the  opposite  side.  The 
fingers  are  habitually  bent,  more  especially  the  ring  and  little 
fingers,  which  are  permanently  flexed  at  both  phalangeal  joints. 
The  thumb  can  be  straightened  completely,  the  fore  and  middle 
fingers  almost  completely,  the  ring  and  little  fingers  very  parti- 
ally, the  first  phalangeal  joint  remaining  bent  at  a  right  angle. 
The  action  of  the  common  extensors  and  flexors  is  unimpaired. 
The  power  of  adduction  and  abduction  of  the  fingers  is  almost 


118  CLINICAL  CASES. 

abolished.  The  thumb  can  be  adducted  and  abducted.  Sensa- 
tion is  abolished  all  over  the  little  finger,  and  over  its  meta- 
carpal bone  on  the  dorsal  and  palmar  aspect  as  far  as  the 
styloid  process  of  the  ulna.  Sensation  on  the  ulnar  side  of  the 
ring-finger  is  diminished,  and  on  the  radial  side  perfect.  Sensa- 
tion over  the  ulnar  two-thirds  of  the  dorsum  of  the  hand  (as 
far  as  the  line  of  the  metacarpal  bone  of  the  middle  finger)  is 
very  much  impaired.  On  the  palmar  side  sensibility  extends 
as  far  as  the  metacarpal  bone  of  the  ring-finger.  The  degree 
of  sensibility  was  tested  by  pricking  with  a  pin,  and  the 
patient,  who  is  a  very  intelligent  young  man,  gave  very 
prompt  and  definite  indications  of  the  sensations  experienced. 

The  skin  of  the  insensible  area  is  somewhat  congested,  but 
there  is  no  vesication  or  breach  of  surface.  There  is  a  hard 
knot  on  the  dorsal  branch  of  the  radial  nerve  about  3  inches 
above  the  wrist.  There  is  a  similar  knot  on  the  great  auricular 
nerve  of  the  left  side  as  it  crosses  the  sterno-cleido-mastoid 
muscle,  and  on  the  frontal  nerve  of  the  right  side.  All  these 
knots  are  painful  on  pressure.  The  ulnar  nerve  is  very  much 
thickened  behind  and  above  the  elbow  to  the  extent  of  about 
5  inches.  It  is  hard  and  cartilaginous  to  the  feel,  as  thick  as 
the  middle  finger,  and  painful  on  manipulation.  There  is  an 
orifice  of  a  sinus  over  the  course  of  the  nerve  situated  about 
4  inches  above  the  inner  condyle  of  the  humerus. 

I  advised  the  patient  to  submit  to  the  operation  of  stretching 
the  ulnar  nerve  as  the  only  expedient  likely  to  benefit  him, 
and  gained  his  ready  consent. 

Operation. — After  bringing  him  under  the  full  influence  of 
chloroform,  and  washing  the  parts  thoroughly  with  carbolic 
lotion,  I  passed  a  director  into  the  sinus,  and  found  that  it 
passed  into  the  interior  of  the  nerve  as  far  as  the  level  of  the 
inner  condyle.  I  slit  the  sinus  up  throughout  its  whole  ex- 
tent. A  long  linear  incision,  exposing  the  nerve  for  a  space  of 
4  inches,  was  the  result.  It  was  hollowed  out  by  an  abscess  of 
which  its  thickened  texture  constituted  the  wall.  This  cavity 
was  filled  with  curdy  material,  and  stuff  of  the  same  kind 
escaped  on  pressure  from  orifices  in  the  abscess  wall.  These 
orifices  led  to  small  chambers  or  recesses  in  the  mass  of  the 
thickened  nerve.  The  cavity  was  thoroughly  emptied,  and  the 
contents  of  the  flask-shaped  recesses  squeezed  out.  The  lining 
membrane  of  the  main  cavity  was  then  scraped  off,  and  the 
smaller  cavities  carefully  cleaned  out  with  a  small  scoop. 
The  nerve  was  then  split  in  two  from  before  backwards,  and 
the  division  was  prolonged  into  the  comparatively  sound  nerve 
above  and  below,  the  knife  following  as  far  as  possible  the 
direction  of  the  fibres.  The  continuation  of  the  nerve  behind 
the  condyle  was  somewhat  thickened,  and  contained  a  few  cells 


CLINICAL   CASES.  119 

full  of  yellow  curdy  material.  The  operation  was  performed 
under  strict  antiseptic  precautions,  and  the  whole  line  of 
wound  was  very  carefully  brought  together  by  iron  wire  and 
horse-hair  stitches,  after  a  few  threads  of  carbolised  catgut  had 
been  laid  in  it  for  drainage.  Boracic-acid  ointment,  spread  on 
muslin,  was  applied  next  the  wound,  and  the  ordinary  carbolic 
gauze-dressing  placed  so  as  to  reach  to  the  axilla  above  and 
half-way  down  the  forearm  below.  The  dressing  was  removed 
every  second  or  third  day,  according  to  circumstances.  Con- 
valescence was  satisfactory.  An  attack  of  ague  occurred  during 
the  second  day,  which  yielded  to  quinine.  The  neighbourhood 
of  the  wound  was  intensely  sensitive  for  the  first  ten  days  or 
so.  The  wound  remained  sweet  and  healed  kindly.  The 
following  notes  were  taken  on  the  21st  of  January,  1880 — 24 
days  after  the  performance  of  the  operation  : — 

"  Cicatrix  completely  healed.  No  abnormal  sensibility  in  the 
neighbourhood  of  the  wound.  The  thickened  nerve  is  still 
perceptible  beneath  the  cicatrix,  but  it  is  not  so  hard  or  bulky 
as  before  the  operation.  There  is  no  evidence  of  deep  matter 
nor  sinus.  Above  the  cicatrix  the  nerve  is  slightly  thickened 
and  very  sensitive  ;  below  the  cicatrix  the  nerve  is  also  some- 
what thickened  and  sensitive,  but  less  so  than  above.  The 
flexor  carpi  ulnaris  is  still  atrophied.  He  straightens  his 
little  and  ring-fingers  rather  better,  and  separates  his  fingers 
with  more  force  and  effect.  The  muscles  of  the  hand  are  still 
very  much  wasted,  and  the  tendons  very  prominent.  There  is 
still  slight  congestion  of  the  dorsal  surface  of  the  ungual  pha- 
lanx of  the  little  finger.  Painful  sensation  is  elicited  by  the 
prick  of  a  pin  all  over  the  hand,  except  over  a  narrow  strip  on 
the  dorsum  of  the  little  finger,  as  far  as  within  half  an  inch  of 
the  styloid  process.  Pinching  with  the  finger  and  thumb, 
however,  produces  pain  up  to  the  first  phalangeal  joint ;  be- 
yond that  there  is  no  sensation,  or  perception  of  pricking,  or 
pinching,  but  when  the  end  of  the  finger  is  forcibly  squeezed, 
pain  is  caused." 

Remarks. — The  condition  for  which  the  operation  above 
described  was  resorted  to  is,  as  far  as  my  experience  goes,  a 
very  rare  one.  I  have  frequently  seen  thickened  nerves  leading 
to  anaesthesia  and  impaired  motility  over  the  area  supplied  by 
them ;  but  I  have  never  before  seen  a  nerve  hollowed  out  in 
this  fashion  by  an  abscess,  and  the  seat  of  curdy  deposits.  In 
this  patient  three  nerves  were  the  subject  of  thickening,  and 
,two  of  them  of  abscess  and  sinus.  The  ulnar  nerve  appears  to 
be  specially  liable  to  this  thickening.  Dr.  Laurie,  acting  on  a 
suggestion  which  I  threw  out  in  1877,  stretched  this  nerve  in 
30  cases  in  which  thickening  and  anaesthesia  existed  ('  Indian 


120  CLINICAL  CASES. 

Medical  Gazette,'  vol.  xiii.,  pages  229, 270),  and  in  all  of  which 
the  operation  produced  benefit.  In  two  cases,  regarding  which  he 
has  been  able  to  obtain  information,  marked  and  permanent 
improvement  was  experienced  ;  and  in  a  similar  case,  which  I 
reported  at  length  in  the  August  (1879)  number  of  the  same 
journal,  restoration  of  sensibility  and  power  followed  very 
speedily  upon  the  stretching  of  the  thickened  nerve.  In  the  pre- 
sent instance  stretching  was  not  resorted  to — simply  laying  open 
and  splitting  the  nerve — and  although  the  patient  did  not 
recover  sensibility  or  muscular  power  fully,  the  notes  of  the  con- 
dition before  and  after  the  operation  leave  no  doubt  that  very 
considerable  amelioration  was  caused  by  the  operation  in  both 
respects.  How  the  operation  of  mechanical  stretching  restores 
the  function  of  the  nerve  I  am  not  prepared  to  say.  The 
case  now  recorded  would  render  it  probable  that  amendment 
is  produced  by  removing  tension  and  pressure  upon  the  nerve 
fibrils.  The  case  is  also  interesting  in  demonstrating  the 
function  of  the  interossei  and  lumbricales  muscles  in  extend- 
ing the  two  terminal  phalanges.  Their  tendons  join  the  ex- 
tensor aponeurosis  on  the  dorsal  surface  of  these  phalanges. 
There  was  no  impairment  of  power  of  the  common  or  special 
extensors,  but  the  paralysis  of  the  interossei  and  lumbricales 
caused  permanent  flexion  of  all  the  fingers,  and  when  the 
function  of  the  ulnar  nerve  was  partially  restored,  the  fingers 
could  be  better  straightened. 


CASES  OF  INTRACRANIAL  TUMOUR, 

BY   JAMES  ROSS,  M.D., 
Assistant-Physician,  Manchester  Royal  Infirmary. 

Case  II. — Samuel  Holmes,  set.  7  years,  presented  himself  as 
an  out-patient  at  the  Southern  Hospital,  Manchester,  on 
January  26th,  1876. 

The  following  history  was  elicited  from  the  mother : — He 
was  a  bright,  intelligent,  and  healthy  boy  until  about  15 
months  ago,  when  he  fell  from  a  wall,  5  feet  high,  and  raised  a 
lump  on  his  forehead.  Soon  afterwards  he  complained  of  con- 
stant headache,  chiefly  confined  to  the  forehead.  The  top  of 
the  head  was  also  so  sensitive  that  combing  his  hair  caused  him 
much  pain.  He  could  not  keep  still ;  his  legs,  especially, 
were  constantly  moving,  and  at  meal  times  he  was  in  the 
habit  of  knocking  the  table  with  his  right  hand,  as  if  from  im- 
patience. About  nine  months  ago  the  mother  noticed  that  his 
mouth  was  slightly  "  crooked,"  and  that  his  left  arm  hung 
helplessly  by  his  side.  The  forearm  was  twisted  so  that  the 
palm  of  the  hand  was  directed  outwards  and  the  thumb  back- 
wards, his  fingers  were  bent,  but  she  thinks  his  thumb  at  first 
was  held  straight  and  drawn  away  from  the  fingers.  After 
some  weeks,  however,  the  thumb  became  bent  inwards  under 
the  index-finger,  and  she  had  to  pare  the  nail  of  the  thumb 
frequently  to  prevent  its  cutting  the  skin  of  the  outside  of 
the  middle  finger.  He  now  began  to  drag  the  left  foot  in 
walking,  and  the  forearm  was  gradually  drawn  up  behind  his 
back,  instead  of  hanging,  as  at  first,  by  his  side. 
i  The  mother  had  nine  of  a  family,  no  miscarriages  and  no 
still-born  children.  One  child  died  from  convulsions  during 
teething  ;  a  second  child,  who  was  weakly  from  birth,  died  at 
three  months  of  age  ;  and  a  daughter  has  suffered  for  the  last 
two  years  from  white  swelling  of  the  knee. 

On  presenting  himself  at  the  hospital  he  was  a  well-made 
and  fully-developed  boy  for  his  years.  His  head  was  large, 
but  weil-proportioned  ;  face  round  and  plump,  although  pallid  ; 
his  incisor  teeth  were  regular,  his'  nose  was  well  formed,  the 


122  CLINICAL   CASES. 

muscular  system  was  well  developed,  and  there  was  abundance 
of  subcutaneous  fat.  There  was  very  well-marked  left  facial 
paralysis,  so  that  the  left  corner  of  the  mouth  could  not  be 
moved  in  the  slightest.  Both  eyes  could  be  closed;  the 
pupils  were  large,  equal,  sensitive  to  light,  and  there  was  no 
affection  of  the  special  senses.  The  left  elbow  was  kept  a 
little  behind  the  mesial  plane,  and  2  inches  from  the  side  ;  the 
forearm  was  bent  at  right  angles  to  the  arm,  and  drawn  behind 
the  body  ;  the  hand  was  strongly  pronated ;  the  thumb  was 
adducted,  and  the  second  phalanx  flexed,  so  that  the  point 
rested  against  the  second  phalanx  of  the  middle  finger.  The  first 
phalanges  of  the  fingers  were  extended  and  in  a  line  with  the  me- 
tacarpal bones,  and  the  second  and  third  phalanges  were  flexed. 
A  considerable  amount  of  muscular  rigidity  was  induced  on 
attempting  passive  motion  at  the  elbow  and  wrist  joints.  By 
a  voluntary  effort  he  could  raise  his  elbow  to  nearly  the  level 
of  the  shoulder,  and  bring  the  upper  arm  slowly  forwards ;  but 
he  could  neither  extend  the  forearm,  produce  supination,  nor 
extend  the  fingers.  The  left  leg  dragged  during  walking,  but 
there  was  no  muscular  rigidity,  and  all  the  movements  of  the 
leg  could  be  separately  performed.  The  electro-cutaneous 
sensibility  of  the  left  half  of  the  body  was  increased,  especially 
over  the  back  of  the  left  hand,  and  the  left  half  of  the  face  and 
side  of  the  head.  The  slightest  touch  of  the  skin  over  the 
vertex  of  the  head  to  the  left  of  the  middle  line  caused  the 
patient  to  wince,  and  the'  cutaneous  sensibility  to  pain  was 
increased  over  the  left  half  of  the  body  generally.  The  other 
organs  were  healthy,  and  there  was  no  albumen  or  sugar  in 
the  urine.  He  was  ordered  four  grains  of  iodide  of  potassium 
three  times  a  day ;  but,  as  no  improvement  took  place,  he  was 
admitted  into  the  hospital  on  February  28th. 

March  10th,  1877. — He  was  ordered,  on  admission,  fifteen 
minims  of  the  syrup  of  the  iodide  of  iron,  to  be  taken  three 
times  a  day,  and  the  daily  application  of  a  weak  constant 
current  to  the  paralysed  muscles  and  nerves.  After  two  appli- 
cations of  the  constant  current  he  could  extend  his  fingers  to 
a  slight  extent,  and  in  a  few  days  he  was  able  to  raise  his  hand 
to  the  back  of  his  head.  It  was  observed,  however,  that  the 
most  marked  improvement  took  place  at  the  shoulder-joint ; 
and  that  improvement  in  the  movements  of  the  forearm  and 
hand  was  only  to  a  slight  extent.  This  improvement  was  of 
short  duration,  and  he  now  looks  decidedly  worse  than  on 
admission.  The  pallor  of  the  face  is  much  increased  ;  his 
appetite  has  failed;  the  pulse  is  110,  weak  and  irregular;  and 
the  nurse  says  that  he  has  become  very  stupid.  Ordered  to  be 
kept  in  bed,  milk  diet  and  a  saline  mixture. 

March  18th. — Since  last  report  he  has  got  steadily  worse,  lias 


CLINICAL   CASES.  123 

vomited  frequently,  and  today  he  has  been  seized  with  general 
convulsions.  The  convulsions  frequently  occurred  for  the  next 
two  days,  and  he  did  not  recover  consciousness  in  the  intervals, 
and  died  early  on  March  21st. 

Sectio  cadaveris,  twelve  hours  after  death.— On  opening  the 
skull,  the  convolutions  of  the  brain  presented  a  flattened  and 
compressed  appearance,  and  about  2  ounces  of  fluid  escaped 
during  removal.  The  brain  weighed  51  ounces.  On  slicing 
the  brain  to  a  level  with  the  corpus  callosum  the  upper  surface 
of  a  tumour  was  exposed,  which  was  situated  in  the  centrum 
ovale  of  the  right  hemisphere,  immediately  to  the  right  of  the 
corpus  callosum  and  at  the  junction  of  the  anterior  and  middle 
lobes.  On  opening  the  lateral  ventricles,  this  tumour  was 
felt  as  a  hard  nodule,  slightly  projecting  into  the  right  lateral 
ventricle,  and  occupying  the  position  of  the  caudate  nucleus 
and  anterior  portion  of  the  optic  thalamus,  and  only  covered 
by  the  ependyma  of  the  ventricle.  The  tumour  measured 
three-quarters  of  an  inch  in  the  transverse  and  an  inch  in  the 
antero-posterior  and  vertical  diameters  respectively,  so  that  not 
only  the  caudate  nucleus  and  anterior  portion  of  the  optic 
thalamus,  but  also  the  anterior  two -thirds  of  the  internal  cap- 
sule and  the  anterior  portion  of  the  lenticular  nucleus  were 
destroyed  by  it. 

The  growth  was  pretty  sharply  defined  from  the  surrounding 
brain-tissue,  and  on  section  it  presented  an  outer  grey,  some- 
what vascular  cortex,  about  two  lines  thick,  and  a  central  core 
of  a  yellow  colour,  and  apparently  destitute  of  any  structure. 

Microscopic  examination  showed  that  the  grey  cortex  of  the 
tumour  consisted  of  giant  cells,  each  surrounded  by  lymphoid 
cells  imbedded  in  a  fibrillated  reticulum. 

•The  right  lung  was  closely  adherent  to  the  chest  wall  and  to 
the  diaphragm.  The  lung  itself  was  congested,  but  every 
portion  of  it  floated  in  water.  No  tubercles  nor  cheesy  glands 
were  discovered,  and  the  other  organs  were  healthy. 

Remarks. — The  progressive  character  of  the  symptoms  in 
this  case,  as  well  as  the  fact  that  its  origin  dated  from  a  fall 
on  the  head,  pointed  from  the  first  to  the  growth  of  an  intra- 
cranial tumour.  My  diagnosis,  therefore,  was  tumour,  probably 
tubercular,  of  the  right  corpus  striatum.  At  that  time  I  was 
not  aware  of  the  full  significance  of  the  fibres  which  pass 
through  the  internal  capsule  to  reach  the  cortex  of  the  brain. 
Looking  back  on  the  case  now,  I  think  it  probable  that  the 
tumour  began  first  to  grow  from  one  of  the  arteries  which 
branch  from  the  middle  cerebral  artery  and  pass  through  the 
anterior  perforated  space  to  reach  the  caudate  nucleus  of  the 
corpus  striatum.     It  has  occurred  to   me  that  the  thumping 


124  CLINICAL   CASES. 

movement  of  the  right  hand  described  by  the  mother  might 
really  have  taken  place  in  the  left  hand,  and  that  these,  along 
with  the  other  restless  movements,  might  have  been  due  to 
primary  irritation  of  the  left  caudate  nucleus  or  the  nodus 
cursiosus  of  Nothnagel.  This  supposition,  however,  is  too 
doubtful  for  any  reliance  to  be  placed  upon  it.  The  paralysis 
is  to  be  explained  on  the  supposition  that  the  fibres  of  the 
middle  third  of  the  internal  capsule,  and  which  connect  the 
cortex  of  the  brain  with  the  spinal  cord,  were  gradually  com- 
pressed by  the  progressively  increasing  size  of  the  tumour. 
These  fibres  were  therefore  compressed  from  before  back- 
wards, and  it  is  important  to  notice  that  the  left  half  of  the 
face  was  more  paralysed  than  the  upper  extremity,  and  the 
upper  much  more  paralysed  than  the  lower  extremity. 

The  peculiar  position  occupied  by  the  forearm  and  hand 
is  also  interesting  in  connection  with  the  gradual  com- 
pression of  the  motor  tract  in  its  passage  through  the  internal 
capsule.  The  sensory  disturbances  were  probably  due  to  irri- 
tation of  the  fibres  of  the  posterior  third  of  the  internal  cap- 
sule. Veyssiere  has  proved  that  section  of  these  fibres  in  dogs 
is  followed  by  hemiansesthesia  of  the  opposite  side,  and  the  cases 
recorded  by  Dr.  Hughlings-Jackson  and  others  show  that  a 
lesion  of  the  posterior  portion  of  the  optic  thalamus,  involving 
the  posterior  fibres  of  the  internal  capsule  and  the  external 
geniculate  body,  is  attended  by  hemi-anoesthesia  of  the  opposite 
side  along  with  hemiopia.  It  may,  therefore,  be  inferred  that 
irritation  of  these  fibres  will  cause  hemi-hyperresthesia  of  the 
opposite  side. 


CASE  OF  ALTERNATE  HEMIPLEGIA,  WITH  CONJU- 
GATE DEVIATION  OF  THE  EYES. 

BY  ALEXANDER  M.  McALDOWIE,  M.D., 

Resident  Medical  (Officer,  North  Staffordshire  Infirmary. 

In  March  1876  I  was  sent  for  to  see  John  S.,  aged  29,  a 
labourer,  stated  to  be  suffering  from  a  "  stroke  of  paralysis." 

The  following  history  was  elicited : — 

The  patient  contracted  syphilis  eight  years  ago,  and  suffered 
from  ulcerated  throat  and  skin  eruptions  for  several  years 
subsequent  to  the  chancre,  but  has  been  free  from  these  com- 
plaints for  more  than  two  years.  Has  been  troubled  with 
pains  in  the  shins  and  arms  for  nearly  six  months,  and  from 
dull  aching  pains  in  the  occipital  reo-ion,  together  with  giddi- 
ness, almost  every  night  for  the  past  three  months.  Four  days 
ago  the  patient  suddenly  lost  the  use  of  the  right  arm  and  leg- 
while  dressing  himself  in  the  morning.  There  was  no  loss  of 
consciousness  at  the  time  of  the  attack,  although  the  patient 
felt  giddy  and  his  eyesight  grew  dim.  The  power  of  speech 
was  lost  for  some  hours.  Patient  had  felt  no  premonitory 
symptoms. 

Present  condition. — Patient  well  nourished.  Intellect  very 
good.  Complains  of  severe  pain  in  the  occipital  region.  Pain 
heavy  and  dull  in  character,  most  intense  during  the  night.  Total 
paralysis  of  the  upper,  and  almost  entire  loss  of  power  over  the 
lower,  extremity  on  the  right  side.  (Patient  states  that  the 
paralysis  of  the  leg  was  complete  for  two  days  after  the  attack.) 
Sensation  greatly  diminished  in  the  paralysed  limbs ;  electrical 
excitability  impaired ;  sensation  of  heat  and  cold  normal. 
Complete  paralysis  of  the  left  side  of  the  face.  Tongue  pro- 
truded straight.  Speech  thick  and  very  indistinct,  but  no 
aphasia.  Ptosis  of  left  eyelid ;  slight  twitching  of  right  upper 
eyelid.  Marked  deviation  of  both  eyes  to  the  right,  the 
patient  being  unable  to  turn  them  towards  the  left  beyond  the 
middle  line.     Pupils  natural  in  size,  react  readily  to  stimulus 


126  CLINICAL   CASES. 

of  light.  Ophthalmoscopic  appearances  normal,  both  discs 
pale,  outline  well  defined,  vessels  natural.  Nothing  abnormal 
detected  on  examination  of  the  chest  and  abdomen. 

Ordered  10  grs.  of  iodide  of  potassium  three  times  a  day. 

The  patient  improved  steadily  under  treatment.  The  de- 
viation of  the  eyes  disappeared  about  three  weeks  after  the 
attack,  but  the  facial  paralysis  lasted  for  nearly  two  months. 
He  regained  the  power  of  the  leg  so  as  to  be  able  to  walk  fairly 
well.  The  arm  remained  very  weak,  the  patient  being  able  to 
use  the  hand  and  forearm,  but  was  unable  to  raise  the  limb  to 
the  horizontal  position. 

The  treatment  was  anti-syphilitic  throughout,  iodide  of 
potassium  being  administered  at  first,  afterwards  liquor 
hydrargyri  perchloridi,  and  finally  biniodide  of  mercury. 

The  patient  was  lost  sight  of  about  four  months  after  the 
attack. 

Remarks. — A  case  of  hemiplegia  alternans  with  conjugate 
deviation  of  the  eyes,  is  of  considerable  interest  and  worthy  of 
record.  • 

Alternate  hemiplegia  is  the  most  characteristic  symptom  of 
disease  of  the  lower  part  of  one  lateral  region  of  the  pons.  In 
this  case  the  lesion  was  evidently  situated  at  the  lower  part  of 
the  left  side,  involving  the  fibres  of  the  facial  nerve  below 
their  decussation  in  the  pons,  and  the  motor  fibres  for  the 
limbs  above  their  decussation  in  the  medulla. 

The  completeness  of  the  facial  paralysis  observed  in  this 
case  is  also  a  prominent  sign  of  disease  in  this  region. 
Bastian  says  that  in  lesions  in  this  part  "we  have  an  un- 
usually well-marked  facial  paralysis  on  the  side  of  the  brain 
lesion,  and  a  more  or  less  complete  motor  and  sensory 
paralysis  of  the  limbs  of  the  opposite  side."  And  Nothnagel 
observes :  "  In  this  variety  of  facial  paralysis  of  cerebral  origin, 
all  the  branches  of  the  facial  nerve,  even  those  supplying  the 
frontalis,  corrugator  supercilii,  and  orbicularis  palpebrarum, 
are  involved,  just  as  in  the  peripheral  form  of  this  affection ; 
whereas,  when  the  lesion  is  situated  in  the  upper  part  of  the 

Eons,  at  least  in  the  cases  which  I  have  observed,  these 
ranches  escape." 
The  conjugate  deviation  of  the  eyes  from  the  side  of  the 
brain  lesion  and  towards  the  paralysed  limbs  noted  in  the 
above  case,  also  points  to  a  lesion  of  the  pons.  Prevost  was 
the  first  to  point  out  that  the  deviation  of  the  eyes  follows  a 
constant  law,  being  always  towards  the  side  of  the  brain  lesion. 
The  only  exceptions  that  he  admits  are  affections  of  the  pons 
and  medulla,  when  the  deviation  may  be  away  from  the  side  of 
the  brain  affected.     Bernhardt  argues  that  this  symptom  has 


CLINICAL  CASES.  127 

no  diagnostic  value,  but  the  small  number  of  exceptions  that 
he  brings  forward  only  show  that  the  law  is  not  so  constant  as 
Prevost  maintains.  Taken  in  connection  with  the  alternate 
hemiplegia  observed  in  this  case,  the  symptom  is  of  importance 
in  aiding  us  to  localise  the  disease. 

As  to  the  nature  of  the  affection,  judging  from  the  history 
and  the  result  of  the  treatment  adopted,  there  can  be  no  doubt 
but  that  the  disease  was  of  syphilitic  origin,  probably  the  first 
form  of  "  syphilitic  new-growth  "  described  by  Heubner. 


CKUKAL    MONOPLEGIA— LIMITED    COETICAL 
LESION  OF  OPPOSITE  HEMISPHEEE. 

BY   DAVID   FERRIER,   M.D.,   F.R.S. 

King's  College  Hospital,  and  National  Hospital  for  the  Paralysed  and  Epileptic. 

On  November  18th,  1879,  I  saw  S.  W.,  tetat.  40,  of  whose  case 
the  following  are  chief  particulars,  as  furnished  me  by  Dr. 
Brookhouse,  of  New  Cross,  with  whom  I  saw  the  patient  in 
consultation. 

The  patient  was  first  seen  by  him  on  Sept.  21st,  1879,  and 
had  been  feeling  "  out  of  sorts "  for  a  week  previously  with 
symptoms  of  what  he  called  a  bad  cold.  He  had  a  tempe- 
rature of  101°  F.,  pulse  100,  anxious  expression,  and  some 
abdominal  tenderness,  but  no  diarrhoea.  He  had  a  slight 
cough,  but  there  were  no  abnormal  physical  signs  on  ausculta- 
tion and  percussion. 

His  symptoms  fluctuated  between  this  time  and  October  9th, 
but  he  became  weaker ;  his  appetite  became  impaired,  his 
tongue  coated  and  flabby,  and  his  breathing  became  laboured 
on  exertion.  Nothing  could  be  detected  on  careful  examina- 
tion of  the  lungs  except  a  few  moist  rales  at  the  right  base 
posteriorly.  The  symptoms  in  many  respects  resembled 
typhoid. 

On  Oct.  24th  he  complained  of  some  stiffness  in  the  left 
leg,  and  inability  to  move  it  so  freely  as  the  right.  On  the 
25th  it  became  still  more  feeble,  and  on  the  26th  it  became 
completely  paralysed  as  to  motion. 

This  continued  till  Oct.  28th,  when  he  said  that  he  feared 
the  left  arm  was  "  going  like  the  leg."  The  grasp  of  the  left 
hand  was  distinctly  feebler  than  the  right.  Next  day  the 
feebleness  was  still  more  pronounced,  and  by  the  31st  the  left 
arm  had  become  completely  paralysed  like  the  leg. 

During  the  night  of  Nov.  b*th,  he  had  a  series  of  convulsive 
movements  of  the  left  leg  and  arm,  commencing  in  the  leg 
and  lasting  half  an  hour. 

From  this  date  the  patient  grew  worse.     His  temperature 


CLINICAL   CASES.  129 

ranged  between  99°  and  102°  •  4  F.,  there  being  no  marked 
difference  between  morning  and  evening  temperatures.  There 
was  no  dulness  in  the  lungs,  but  fine  crepitation  on  both  sides 
posteriorly.  There  was  much  cough,  with  frothy  yellowish 
spatum,  but  quite  free  from  any  rusty  appearance. 

On  Nov.  18th  I  saw  the  patient  with  Dr.  Brookhouse  with 
a  special  view  to  determine  the  nature  of  the  paralytic  affec- 
tion. The  patient  was  somewhat  flushed,  breathing  rapidly 
and  with  an  appearance  of  oppression  when  he  spoke,  coughing 
a  good  deal  and  expectorating  frothy  mucus.  His  tempera- 
ture taken  on  the  right  axilla  was  102°  F.,  while  on  the  left 
axilla  it  was  102°  •  8  F. 

There  were  no  symptoms  of  extensive  cerebral  disease.  The 
mind  was  clear.  There  was  no  headache  or  vomiting,  and 
examination  of  the  discs  revealed  nothing  abnormal. 

There  was  nothing  abnormal  discoverable  on  examination 
of  the  abdomen.  The  urine  was  free  from  albumen.  The 
lungs  were  resonant  throughout,  but  there  were  moist  sounds 
at  the  base  posteriorly,  particularly  on  right  side.  On  exami- 
nation of  the  limbs  the  left  leg  and  left  arm  were  seen  to  be 
perfectly  flaccid  and  powerless.  There  was  a  total  loss  of  voli- 
tional power.  There  was  no  trace  of  facial  paralysis.  Both 
sides  acted  equally  well,  and  the  tongue  was  protruded 
straight. 

There  was  increased  tendon  reflex  in  the  left  leg.  Sensa- 
sation  was  unimpaired.  The  slightest  touch  on  any  part  of 
the  left  arm  or  leg  was  distinctly  perceived  and  accurately 
localised. 

The  patient  had  had  syphilis  and  had  lately  been  under 
specific  treatment,  owing  to  suspicious  syphilitic  ulceration 
of  the  tongue.  A  sister  had  died  of  acute  tuberculosis.  From 
a  consideration  of  the  past  history  and  symptoms  presented 
by  the  patient,  I  formed  the  opinion  that  the  constitutional 
symptoms  and  febrile  excitement  depended  mainly  on  acute 
infiltration  of  the  lungs,  either  tubercular  or  syphilitic,  and 
that  the  paralysis  depended  on  a  limited  lesion  of  the  cortex, 
progressive  in  character,  and  situated  at  the  upper  extremity 
of  the  fissure  of  Bolando  on  the  right  hemisphere. 

An  unfavourable  prognosis  was  pronounced. 

No  specially  fresh  symptoms  occurred,  but  the  patient 
gradually  sank  and  died  on  Nov.  24th,  in  a  state  of  coma. 

Post-mortem  examination. — On  November  26th  we  made  a 
post-mortem  examination,  but  had  to  confine  our  examination 
to  the  head  and  partial  exploration  of  the  thorax. 

The  skull-cap  was  easily  detached  and  was  free  from 
adhesions.  The  dura  mater  was  also  easily  separable,  except 
for  slight,  easily  broken  down,  adhesion  at  the  middle  line  at 

VOL.   III.  k 


130  CLINICAL  CASES. 

a  region  corresponding  to  the  upper  extremity  of  the  fissure 
of  Eolando  on  the  right  side.  The  subarachnoid  space  con- 
tained some  fluid,  but  clear  and  free  from  opacity.  The  pia 
mater  was  everywhere  normal  and  separated  readily  from  the 
cortex  except  at  one  spot.  This  was  situated  at  the  upper 
margin  and  internal  aspect  of  the  right  hemisphere,  on  both 
sides  of  the  fissure  of  Eolando,  where  the  pia  mater  merged 
into  a  caseous  adhesion  not  appreciably  elevated  above  the 
rest  of  the  cortex,  but  which  could  not  be  removed  without 
tearing  the  cortical  substance,  and  causing  erosion. 

On  further  careful  examination  of  the  position  and  extent 
of  the  lesion,  the  following  notes  were  made : — 

The  pia  mater  was  adherent  and  studded  with  minute 
tubercular  foci,  of  a  yellowish  aspect,  on  the  internal  aspect  of 
the  hemisphere  at  the  point  where  the  fissure  of  Eolando 
terminates.  The  adhesion  was  of  a  quadrilateral  shape, 
measuring  1  in.  antero-posteriorly  and  f  in.  vertically.  (The 
position  and  extent  of  the  lesion  here  will  easily  be  under- 
stood by  reference  to  Ecker's  figure  of  the  internal  aspect  of 
the  hemisphere.  It  occupied  an  area  which  would  be  included 
between  the  letters  A  and  b,  and  concealing  c.) 

Doubling  over  the  margin  of  the  hemisphere  the  adhesion 
separated  the  extreme  upper  lips  of  the  fissure  of  Eolando 
from  each  other,  and  descended  along  the  bottom  of  this 
fissure,  coming  to  a  point  an  inch  below  the  margin  of  the 
hemisphere.  The  whole  area  and  shape  of  the  lesion  may  be 
likened  to  a  triangle,  the  base  of  which  would  measure  1  inch, 
and  the  height  If  inch  or  2  inches  at  the  utmost,  applied 
with  its  base  at  the  internal  termination  of  the  fissure  of 
Eolando,  and  doubled  over  the  margin  with  its  apex  directed 
along  the  bottom  of  this  sulcus. 

Eemoval  of  the  adherent  membrane  caused  tearing  and 
erosion  of  the  cortex,  but  quite  superficially ;  the  medullary 
substance  underneath  being  injected  but  not  softened. 

The  degeneration  was  most  advanced  internally  and  at  the 
extreme  upper  margin  of  the  hemisphere,  as  indicated  by  the 
caseous  softening  of  the  miliary  tubercles. 

There  was  no  excess  of  fluid  in  the  ventricles,  and  the  rest 
of  the  brain  was  normal  throughout. 

The  lungs,  portions  of  which  were  removed  and  examined 
microscopically  were  studded  throughout  with  miliary  tubercles, 
feeling  to  the  touch  as  if  infiltrated  with  small  shot.  There 
were  no  cavities  or  areas  of  softening. 

The  other  viscera  were  not  examined. 

BemarJcs. — This  is  an  important  addition  to  the  compara- 
tively small  number  of  clinical  cases  serving  to  indicate  the 


CLINICAL  CASES.  131 

position  of  the  leg-centre  in  the  cortex.  It  is  an  altogether 
uncomplicated  instance  of  purely  cortical  lesion,  so  definite  as 
almost  to  compare  with  a  physiological  experiment.  Though 
the  paralysis  did  not  remain  confined  to  the  leg  throughout, 
yet  the  fact  that  it  did  so  for  four  days  clearly  proves  that  the 
leg-centre  is  capable  of  differentiation  from  those  of  the  arm, 
though  they  are  so  commonly  implicated  together.  The  point 
where  the  lesion  began  is  indicated  by  the  region  where 
the  caseous  degeneration  was  most  advanced.  This  was  the 
inner  aspect  and  margin  of  the  hemisphere  on  each  side  of  the 
upper  extremity  of  the  fissure  of  Rolando.  This  situation 
accurately  corresponds  to  the  areas — 1  and  2 — which  I  have 
indicated  on  the  monkey's  brain  as  comprising  the  centres  for 
the  various  movements  of  the  leg.  The  extension  of  the 
paralysis  to  the  arm  is  in  accordance  with  the  advance  of  the 
lesion  along  the  fissure  of  Rolando. 

The  diagnosis — which  I  made  with  confidence  from  the  mode 
of  onset  and  its  progress,  the  character  of  the  paralysis,  and 
absence  of  general  cerebral  symptoms — of  a  limited  cortical 
lesion  of  a  progressive  character,  situated  primarily  at  the 
upper  extremity  of  the  fissure  of  Rolando,  was  completely 
verified  by  post-mortem  examination.  The  case  shows  inter 
alia  that  with  lesions  strictly  cortical  there  may  be  the  most 
absolute  motor  paralysis,  with  perfectly  intact  cutaneous 
sensibility  ;  and,  further,  that  with  cortical  lesions  vaso-motor 
paralysis  is  associated  with  motor  paralysis,  as  indicated  by  the 
higher  temperature — '8°  F. — of  the  paralysed  side. 


k  2 


%hBtxnth  at  griixsfr  anb  Jtowibp  Jfmtntals. 
Innervation   des  Vaisseaux   cutane*s,  Dastre  et  Morat. 

{Archives  de  Physiologie,  Mai — Aout,  1879.) — The  above  paper 
enters  into  an  exhaustive  critique  of  vaso-dilatation,  and  furnishes 
certain  precise  data  towards  the  solution  of  its  problem.  The 
central  origin  of  vaso-constrictor  nerves  is  first  discussed — it  is 
now-a-days  proven  that  they  are  associated  with  the  anterior  spinal 
roots,  the  dorsal  division  of  the  cord  being  their  principal  focus  of 
origin ;  but  there  is  a  further  centralisation  of  influence  within  a 
limited  portion  of  the  bulb,  the  general  tonic  centre  or  vaso-motor 
centre  of  Owsjannikow ;  and  vaso-motor  centres  have  further  been 
assigned  even  in  the  cortex.  Of  the  degree  of  centralisation  and 
of  the  relative  independence  of  an  axial  series  of  spinal  centres, 
D.  and  M.  remark  that  the  universal  influence  of  the  bulbar  centre 
is  undeniable,  but  that  this  influence  is  not  exclusive — the  con- 
clusion is  that  vaso-constrictor  activity  has  one  chief  source  (bulbar) 
and  several  accessory  sources  (spinal  and  encephalic).  Still  another 
element  comes  into  account — the  possible  or  probable  existence  of 
peripheral  tonic  centres  (Huizinga)  constituted  by  the  ganglionic 
cells  in  intrinsic  plexuses  of  the  arterial  wall — intrinsic  arterial 
ganglia.  One  among  many  good  arguments  in  their  favour  is 
as  follows :  a  dilatator  (e.  g.  corda  tympani)  contraction  of  the 
vessels  by  irritation  of  the  sympathetic  is  hindered  by  simultaneous 
irritation  of  the  corda ;  since  the  nerves  run  independently  to  the 
periphery,  it  is  here  that  we  must  presume  some  mechanism  to 
exist  compounding  their  opposite  actions.  The  question  of  dilata- 
tion is  considered  at  length — whether  it  is  by  an  activity  opposed 
to  constriction,  or  merely  by  an  absence  of  constriction. 

The  definition  of  a  dilatator  nerve  is  insisted  upon  as  a  centri- 
fugal nerve  whose  excitation  effects  a  primary  dilatation  of  vessels 
independent  of  any  central  mediation,  thus  excluding  the  confusing 
consideration  of  reflex  dilatations.    We  are  agreed  as  to  the  mecha- 


ABSTRACTS  OF   BRITISH   AND   FOREIGN  JOURNALS.    133 

nism  of  constriction,  not  so  as  to  that  of  dilatation.  Dismissing 
the  notions  of  a  direct  dilatator  influence  of  the  nerve  fibre  on  the 
muscle  fibre,  or  of  the  dilatation  of  arterioles  by  constriction  of 
vemiles,  or  of  exaggerated  peristaltis,  it  cannot  be  denied  that 
every  dilatation  is  a  paresis  of  constriction,  and  before  the  sugges- 
tion of  dilatators  this  was  the  universal  statement ;  but  the  dis- 
covery of  the  dilatator  action  of  the  corda  tympani  led  to  the  gene- 
ralisation of  active  dilatation  opposed  to  contraction,  and  subserved 
by  vaso-dilatators  distributed  with  vaso-constrictors  throughout 
the  body.  Dilatators  were  then  sought  for,  and  nnder  favourable 
circumstances  for  the  most  part  found.  The  sciatic  has  been 
throughout  a  chosen  bone  of  contention ;  the  notorious  discrepan- 
cies of  results  are  attributed  by  D.  and  M.  to  inadequacy  of  tests. 
The  most  employed  has  been  thermometry  ;  less  frequently,  obser- 
vation of  a  bleeding-point  and  plethysmography.  The  thermometer 
is  unsatisfactory,  because  it  is  a  sluggish  test,  and  because  it  is  not 
proved  that  temperature  varies  coincidently  with  dilatation ;  note 
also  that  in  the  scale  of  low  temperatures,  with  constriction  of 
vessels,  dilatation  is  most  readily  manifested  and  its  thermic  effect 
greatest,  and  vice  versa  in  the  scale  of  high  temperatures ;  further 
that  when  vessels  dilate  warmth  increases,  and  dilatation  is  there- 
fore cumulative.  Classing  observers  into :  (1)  those  to  whom  the 
sciatic  is  a  dilatator  (Golz,  Masius,  Vanlair) ;  (2)  those  to  whom  it 
is  constrictor  and  dilatator,  according  to  circumstances  (Onimus, 
Lepine,  Kendall  and  Luchsinger,  Bei-nstein  and  Marchand,  Griitzner 
and  Heidenhain) ;  (3)  those  to  whom  it  is  a  constrictor  (Putzeys, 
Tarchanoff,  Vulpian) — D.  and  M.  remark  that  classes  (1)  and  (2) 
employ  the  thermic  test,  class  (3)  have  recourse  to  direct  observa- 
tion. 

D.  and  M.  resorted  to  manometry. — They  first  estimated  the 
local  variations  of  pressure  effected  by  an  accepted  constrictor 
(sympathetic),  with  these  they  then  compared  the  local  variations 
effected  by  a  mixed  nerve  (plantar  branch  of  sciatic).  The  results 
were  in  either  case  identical.  With  the  sympathetic,  facial  vein 
and  facial  artery  of  horses  or  asses,  they  obtained  with  the  section  of 
symp.  (1)  a  brief  elevation  of  both  pressures  (lasting  6"  to  8"),  due  to 
constriction  of  vessels  by  the  momentary  irritation  of  section,  followed 
by  (2)  a  gradual  rise  of  venous  and  fall  of  arterial  pressure.  With 
tetanisation  of  the  symp.  they  obtained  (1)  a  brief  rise  of  arterial 
and  fall  of  venous  pressure  (20"  to  30")  followed  by  (2)  a  gradual 
return  to  and  beyond  the  previous  state  of  heightened  venous 
lowered  arterial  pressure  (2  to  3  min.).  This  hyperdilatation  is  note- 


134  ABSTRACTS   OF   BRITISH 

worthy ;  it  is  greatest  after  most  intense  stimulation,  and  is  to  be 
regarded  as  an  exhaustion  phenomenon — there  remained  after  sec- 
tion a  tonic  influence — where  ?  in  the  peripheral  centres,  say  D. 
and  M.  With  the  plantar  nerve,  digital  vein  and  digital  artery, 
they  obtained  identical  results.  Hence  the  conclusion  that  there 
is  no  more  reason  to  suppose  dilatators  in  the  sciatic  than  in  the 
sympathetic,  since  in  both  the  effects  of  irritation  are  the  same, 
viz.,  primarily  contraction  ;  secondarily,  dilatation.  Eesumingnow 
the  general  question  of  dilatation,  viz.,  paresis  of  contraction, 
whence  may  the  suspension  of  activity  proceed?  from  spinal  or 
from  peripheral  centres?  In  the  above  experiments  dilatation 
follows  the  interruption  of  an  activity  above  the  section,  the  ex- 
haustion of  an  activity  below  the  section;  on  the  other  hand 
nothing  proves  that  the  paralytic  dilatation  is  a  fatigue,  for  it 
should  then  always  be  preceded  by  a  period  of  contraction,  but  we 
must  admit  that  it  is  a  primary  effect.  The  effects  cannot  here 
be  explained  as  an  inhibitory  interference  of  spinal  over  peripheral 
centres,  and  dilatation  can  probably  occur  in  either  of  two  ways, 
viz.  by  paresis  of  spinal  centres  or  by  paresis  of  peripheral  centres. 

Etude  sur  la  Physiologie  des  Nerfs  des  Muscles  Strips. 

S.  Tschiriew.  (Arch,  de  PJiys.,  1879,  Nos.  3  and  4. — In  a  former 
paper  (Tonus  quergestreifter  Mnskeln,  Arch.  f.  Anat.  u.  Phys., 
Phys.  Abth.  1879,  p.  89.) — T.  pleads  strongly  in  favour  of  the 
existence  and  reflex  mechanism  of  muscular  tonicity.  The  present 
paper  continues  to  consider  the  theory  of  reflex  muscular  action 
by  soliciting  impression,  and  deals  therefore  with  the  nature,  peri- 
pheral source,  channels  and  presiding  centre  of  the  activity. 
Firstly,  with  regard  to  common  sensibility,  he  remarks  that  nor- 
mally muscle  is  insensible  to  pain  by  an  instantaneous  irritation, 
but  sensitive  to  prolonged  irritation,  and  also  in  certain  patho- 
logical states  (myalgia  rheumatica,  cramp,  psoitis,  hysterical  mus- 
cular hyperesthesia,  amyotrophic  lateral  sclerosis),  and  that  the 
phenomenon  of  pain  necessarily  entails  centripetal  nerve-fibres. 
How  do  we  judge  of  weight,  or  of  the  attitude  and  movement  of 
our  limbs?  By  some  a  specific  sense  of  muscular  tension  ("the 
muscular  sense  ")  is  imagined  to  arise  in  the  contracting  fibre ;  by 
others  the  sense  of  effort  is  attributed  to  the  motor  cell,  being  the 
subjective  aspect  and  measure  of  its  intensity  of  action;  and  by 
others  still  "  muscular  sense  "  is  declared  to  be  an  entire  misnomer, 
sensation  being  informed  by  altered  tension,  not  of  the  muscle  but 
of  surrounding  tissues.     T.  declares  in  favour  of  the  peripheral 


AND  FOREIGN   JOURNALS.  135 

origin  of  a  centripetal  muscular  sense  by  virtue  of  a  special  sensi- 
bility. Passing  to  the  question  of  reflex  movements  by  excitation 
of  muscles,  T.  discusses  the  knee-phenomenon,  and  condemns 
the  old  theory  of  direct  excitation  of  muscular  fibre  by  me- 
chanical tension ;  he  refers  it  to  a  dragging  upon  the  aponeurotic 
nerves  by  the  percussion  of  the  already  stretched  tendon,  and 
asserts  that  the  reflex  is  effected  in  that  part  of  the  cord  whence 
the  crural  nerves  originate — he  estimates  the  interval  between 
percussion  and  contraction  at  ^" .  His  general  conclusion  is  that 
muscles  are  connected  with  the  cord  by  motor  nerves  and  also  by 
centripetal  nerves,  viz.,  by  a  nervous  arc. 

In  a  previous  paper  ('  Sur  les  Terminaisons  Nerveuses  dans  les 
Muscles  stries,'  Archives,  1879,  p.  89)  he  claims  to  have  proved 
that  on  striated  fibres  there  are  none  but  motor  terminations,  and 
that  non-medullated  nerves  of  muscle  ending-  by  arborisation  in 
the  aponeuroses  are  those  of  muscular  sensibility. 

Having  regard  to  cases  where  there  is  "  delay  of  pain,"  T.  states 
the  opinion  that  all  sensations  common  and  special  are  conveyed 
to  the  cord  by  common  centripetal  fibres,  but  are  dissociated  into 
separate  channels  by  the  agency  of  the  cells  of  the  grey  matter. 
He  anticipates,  therefore,  that  delay  of  pain  may  be  found  associated 
with  lesions  limited  to  the  posterior  horns  in  correspondence  with 
the  affected  district,  and  conversely  that  impairment  of  sensation 
without  delay  of  pain  should  rule  when  lesions  are  confined  to  the 
posterior  roots  or  columns. 

T.'s  paper  concludes  with  a  criticism  of  Krause's  "  hypothesis 
of  discharge,"  a  hypothesis  based  on  a  fallacious  comparison  of  the 
motor  end-plate  with  the  plate  of  the  electric  organ.  His  pre- 
vious paper  ('  Sur  les  Terminaisons,'  &c.)  went  to  prove  that  the 
terminal  arborisation  of  the  axis-cylinder,  is  the  essential  element 
of  an  end-plate,  and  not  the  granular  layer.  He  adheres  to  Du 
Bois-Eeymond's  "  modified  hypothesis,"  advancing  experiments  to 
show  how  the  shape  of  the  end-plate  should  favour  the  concen- 
tration of  the  excitor  influence  of  a  disturbed  electric  equilibrium. 

Dr.  Gowers  {Med.  Chir.  Trans.,  vol.  lxii.  p.  269;  estimates  the 
mean  "patellar  tendon  reflex"  interval  at  ^j^"  (-09  to  "15),  and 
remarks  that  this  corresponds  with  the  a  priori  time  value  assign- 
able to  the  reflex  act  (viz.,  -045"  for  conduction,  -05"  for  central 
action,  -01"  for  latent  muscular  period).  He  calls  attention  to  a 
small  rise  in  his  tracings,  about  -05"  after  percussion,  and  asks 
whether  this  be  not  the  indication  of  a  direct  muscular  contraction 
by  the  direct  irritation  of  muscular  tension,  the  subsequent  wave 


136  ABSTRACTS  OF  BRITISH 

indicating  the  indirect  contraction  by  the  reflex  excitation  of 
tension.  G.'s  account  of  the  knee-phenomenon  would  thus  include 
both  its  leading  theories,  viz.,  that  of  direct  irritation  and  that  of 
reflex  excitation.  For  the  front-tap  contraction  (a  name  given  by 
G.  to  the  gastrocnemius  contraction,  following  a  sharp  tap  on  the 
anterior  leg  muscles),  he  finds  an  interval  of  'Of  to  -05,  and  con- 
cludes that  the  contraction  is  one  of  direct  irritation.  The  ankle- 
clonus  is  regarded  by  G.  as  due  to  the  direct  stimulation  of  a 
muscular  irritability,  constituted  by  the  reflex  effect  of  tension, 
its  frequency  being  6  to  8  per  sec,  while  the  rare  knee-clonus  is 
regarded  as  reflex  in  mechanism,  its  frequency  being  2*5  per  sec. 
He  considers  clonus  as  an  instance  of  a  rhythmic  action  effected 
by  a  continuous  stimulation. 

Note. — In  the  course  of  measurements,  which  will  be  detailed  elsewhere,  of  the 
interval  between  percussion  and  contraction,  I  fouud  for  the  knee  phenomenon 
•04"  as  its  mean  value  in  normal  subjects  (Gowers,  '09"  to  '15";  Tschiriew, 
•033").  For  the  front-tap  interval  I  found  *035",  *04",  and  *04"  in  three 
cases  where  the  knee  interval  was  measured  to  be  *035",  '04",  and  *045" 
(Gowers,  •  04"  to  '  05").  In  two  other  cases  (paraplegia)  I  found  for  the  ankle- 
clonus  a  spasm  frequency  of  8  and  9  per  sec,  and  for  the  knee-clonus  of  9  and 
10  per  sec. 

I  may  remark  that  a  knee  clonus  does  not  seem  to  be  so  rare  as  it  is  usually 
stated  to  be.  A  priori  we  should  not  expect  a  rectus-clonus  to  be  more  unusual 
than  a  gastrocnemius-clonus,  and  it  is  simply  owing  to  the  respective  circum- 
stances of  the  two  joints,  that  the  spasms  can  commonly  be  elicited  single  in  the 
rectus,  multiple  in  the  gastrocnemius.  In  point  of  fact  a  knee-clonus  may  be 
elicited  by  appropriate  measures  even  in  normal  subjects,  which  is  to  the  patho- 
logical phenomenon  what  the  foot-trepidation  of  a  normal  subject  is  to  its 
exaggeration — ankle-clonus.  I  have  found  the  knee-clonus  in  the  ankle-clonus 
cases  I  have  examined  by  a  flexing  jerk  of  the  rigidly-extended  limb  (best  in  the 
rigidity  of  paraplegics,  where  there  remained  some  degree  of  voluntary  motility). 

The  identity  in  the  time-intervals  of  the  single  spasms  at  the  two  joints  argues 
them  to  be  of  identical  mechanism ;  the  identity  in  the  spasm-frequencies  argues 
these  also  to  be  of  identical  mechanism.  By  other  considerations  that  cannot  be 
entered  upon  here,  I  am  led  to  the  conclusion  that  all  the  spasms  above  referred 
to  are  reflex  from  the  spinal  cord. 

A.  Waller. 

Primary  Athetosis.  Gnauck.  (Arch.  f.  Psych.,  ix.  p.  300.) 
■ — A  girl,  aged  13,  who  had  always  been  healthy  and  had  no  pre- 
disposition to  nervous  disease,  was  seized  with  smarting  pains  in 
the  right  face.  In  eight  days,  continuous  involuntary  movements 
of  the  right  hand  and  foot  were  observed,  and  shortly  afterwards 
slight  drooping  of  the  right  side  of  the  face.  Treatment  with 
bromide  of  potassium  was  followed  by  disappearance  first  of  the 
facial  pains  and  then  of  the  involuntary  movements,  these  last 


AND  FOKEIGN  JOURNALS.  137 

being  completely  gone  in  three  months.  The  drooping  of  the  face 
became  less  noticeable,  but  did  not  disappear.  She  remained  well 
about  three  months,  when  her  old  symptoms  reappeared.  She 
noticed  now  that  in  certain  places  her  sense  of  touch  was  not  as  acute 
on  the  right  as  on  the  left  side.  The  facial  pains  ceased  after  an 
attack  of  epistaxis,  but  the  other  symptoms  persisted.  In  this 
condition  she  consulted  the  author,  who  noted  movements  in  the 
fingers,  hand,  forearm,  toes,  foot,  and  leg  of  the  right  side.  The 
movements  were  slow,  rhythmical,  unceasing,  involuntary,  and 
yet,  as  it  were,  purposive,  and  they  ceased  during  sleep.  There 
was  facial  hypokinesis  on  the  right  side.  The  cutaneous  sensi- 
bility was  somewhat  diminished  in  the  parts  in  which  the  move- 
ments occurred.  But  there  was  no  loss  of  power  in  the  right 
extremities ;  the  electric  irritability  was  unchanged ;  the  reflex 
excitability,  including  the  phenomenon  of  tendon-reflex,  was  normal, 
and  the  circumference  of  the  limbs  was  the  same  on  both  sides. 
Bromide  of  potassium  was  given  in  increasing  doses,  and  the  con- 
tinuous current,  from  the  cervical  and  lumbar  regions  of  the  cord 
downwards  to  the  affected  muscles,  was  applied  every  other  day 
for  about  ten  minutes.  In  a  few  months  the  patient  had  com- 
pletely recovered. 

The  important  points  in  this  case  are  (1)  the  fact  that  the  disease 
occurred  in  an  individual  who  had  previously  enjoyed  good  health ; 
(2)  the  partial  recovery  and  subsequent  relapse ;  and  (3")  the  ulti- 
mate complete  recovery  of  the  patient.  The  case  is  one  of  idio- 
pathic or  primary  athetosis,  as  distinguished  from  secondary  or 
symptomatic  athetosis,  in  which  we  have  a  history  of  hemiplegia, 
epilepsy,  brain  atrophy,  &c.  Of  the  primary  disease  only  five  cases 
are  on  record,  and  Gnauck  gives  a  comparative  analysis  of  them.  In 
the  only  instance  in  which  an  autopsy  was  made,  a  focus  of  soften- 
ing was  found  in  the  '  corpus  striatum  and  lenticular  nucleus '  of 
one  side.  In  the  case  just  reported  there  was  probably  an  affection 
of  the  outer  part  of  the  left  half  of  the  pons.  The  author  dis- 
tinguishes between  symptomatic  athetosis  and  cases  of  athetoid 
movements  :  in  the  former,  the  symptoms  very  closely  resemble 
those  of  primary  athetosis,  in  the  latter,  they  differ  from  these  in 
some  important  respects. 

W.  J.  Dodds,  M.D.,  D.Sc. 

A  Case  confirming  Cerebral  Localisation,    Dr.  Tamburini 

(Ttivista  Sperimentale  di  Freniatria,  Anno  V.  Fascicolo  III.)  gives  an 
account  of  an  imbecile,  45  years  old,  bearing  the  honoured  name  of 
Paul  Veronese.     He  was  subject  to  epileptic  fits,  which  were  often 


138  ABSTRACTS  OF   BRITISH 

followed  by  delirium.  During  an  attack  of  this  kind  ho  killed  an 
idiot  with  a  knife.  The  epilepsy  dated  from  infancy,  and  was 
accompanied  by  atrophy  and  paralysis  of  the  left  arm  and  leg.  He 
was  four  years  and  a  half  in  the  asylum  at  Eeggio,  where  he  died. 
The  fits  had  become  so  frequent  that  they  could  not  be  counted. 
The  attacks  were  always  preceded  by  an  aura;  then  followed  clonic 
movements,  which  began  in  the  paralysed  and  wasted  left  arm. 
Sometimes  the  convulsions  were  limited  to  the  arm,  and  extended 
to  the  face  and  leg  of  left  side ;  sometimes  they  involved  the  whole 
body.  The  face  was  less  developed  on  the  left  side  than  on  the 
right.  In  fact  the  whole  left  side  was  smaller  than  the  right; 
still  the  leg  was  not  so  much  paralysed  as  the  arm.  The  man's 
intelligence  was  very  deficient,  the  power  of  speech  limited,  and 
the  command  of  the  vocal  apparatus  imperfect.  Words  were  pro- 
nounced with  great  effort  and  with  repetition  and  stuttering. 

The  left  hemisphere  of  the  brain  was  found  to  be  normal,  it 
weighed  510  grammes,  but  the  right  hemisphere  was  much  smaller, 
weighing  only  260  grammes ;  the  whole  brain  weighed  930. 
On  the  right  side,  the  ascending  parietal  convolution  (the  poste- 
rior median  of  Ecker)  was  atrophied  and  indurated,  especially  at 
its  external  part.  This  atrophy  and  induration  involved  the 
neighbouring  portion  of  the  ascending  frontal  gyrus  anterior 
median  of  Ecker  and  the  lower  parts  of  the  second  and  third 
frontal  gyri.  Behind  this  circle  of  sclerosed  matter  there  was  a 
cavity  about  the  size  of  a  pigeon's  egg,  full  of  purulent  matter,  ex- 
tending through  the  left  temporal  lobe  and  occupying  the  place  of 
the  island  of  Eeil,  all  vestiges  of  which  had  disappeared.  The 
right  thalamus  opticus,  crus  cerebri,  and  surface  of  the  pons  on  the 
right  side  were  also  found  diminished  in  size  and  hardened  in 
texture.  The  spinal  cord  was  found  atrophied,  especially  on  the 
cervico-dorsal  region.  The  sclerosed  part  examined  by  microscope 
showed  an  increase  in  the  connective  tissues  and  in  the  gyri  round 
the  fissure  of  Sylvius;  amyloid  corpuscles  and  white  cells  were 
found  around  the  vessels. 

Tamburini  remarks  that  the  atrophy  of  the  left  hemisphere  con- 
tinued into  the  crus  cerebri,  the  pons  and  anterior  pyramid  of  the 
same  side,  and  then  passing  into  the  half  of  the  spinal  cord  taken 
into  connection  with  the  atrophy  and  paralysis  of  the  left  side  of 
the  body,  furnishes  a  striking  proof  of  the  dependence  of  the  trophic 
and  motor  functions,  not  only  in  the  cord  and  pons,  but  also  in  the 
cerebral  hemisphere  as  well  as  of  the  crossing  of  the  nervous  tract 
denied  by  Brown-Sequard. 


AND  FOREIGN  JOURNALS.  139 

The  loss  of  power  in  the  left  arm  and  leg  and  in  the  face  is 
explained  by  the  injury  to  the  external  portions  of  the  ascending 
parietal,  the  ascending  frontal,  and  the  lower  part  of  the  third 
frontal. 

The  dissection  of  the  brain,  writes  the  learned  physiologist, 
signally  confirms  the  criterion  for  diagnosis  brought  to  bight  by 
Hughlings-Jackson  and  experimentally  confirmed  by  us  (Tam- 
burini  and  Luciani)  that  the  lesion  of  the  motor  centre  of  the 
cortex  cerebri  may  be  diagnosed  from  the  muscles  first  affected  by 
the  epileptic  attack.  The  injury  to  speech  is  explained  by  the 
destruction  of  the  island  of  Eeil,  which,  in  this  case  be  it  noted, 
was  on  the  right  side  of  the  brain. 

In  considering  the  atrophy  and  sclerosis  of  the  right  optic  tha- 
lamus, Tamburini  enumerates  the  views  of  some  distinguished 
neurologists  on  the  function  of  this  large  basal  ganglion.  Luys 
holds  that  it  contains  four  special  centres  for  the  representation  of 
smell,  sight,  hearing  and  general  sensibility.  Ferrier  thinks  it  to 
be  a  ganglion  of  interruption  or  centre  of  convergence  of  the  sen- 
sory tracts.  Fournier,  Carville,  Duret  and  Crichton-Browne  hold 
that  it  is  a  centre  of  general  sensibility.  Nothnagel  found  that 
destruction  of  the  optic  thalamus  was  followed  by  a  loss  of  sensi- 
bility and  also  of  voluntary  motion.  Meynert,  on  the  other  hand, 
holds  that  the  sensory  impressions  coming  from  the  periphery  are 
transformed  in  the  optic  thalami  into  movements ;  they  are  thus 
the  automatic  centres  of  reflex  unconscious  motions.  Schiff, 
Lussana  and  Lemoigne  concluded  from  their  experiments  that  the 
optic  thalami  are  centres  for  the  motions  of  the  arm  and  hand  of 
the  opposite  side.  The  fact  that  in  this  case  the  atrophy  of 
the  optic  thalamus  was  a  continuation  of  the  affection  of  the 
motor  gyri,  induces  Dr.  Tamburini  to  think  that  the  thala- 
mus is  a  conductor  of  the  motor  fibres,  especially  of  the  upper 
limb. 

Hardening  of  the  hippocampus  major  was  found  in  this  case ; 
analysing  the  observations  of  five  pathologists,  he  shows  that  it 
was  found  in  60  epileptics  out  of  272  dissections.  He  is  of  opinion 
that  this  lesion  is  only  found  in  old  cases  of  epilepsy.  According 
to  Meynert,  the  cornu  ammonis  contains  peculiar  pyramidal  cells, 
but  the  destruction  of  the  hippocampus  causes  no  loss  of  any  motor 
powers,  nor  does  its  removal  bring  any  modification  in  epileptic 
convulsions.  Tamburini  recalls  the  views  of  Ferrier,  who  places 
the  seat  of  olfactory  sensation  in  the  subiculum  of  the  hippo- 
campus.    For  these  reasons  he  concludes  that  the  hardening  of 


140  ABSTRACTS   OF  BRITISH 

this  portion  of  brain  has  no  causal  influence  on  the  production  of 
epilepsy.  He  considers  that  the  morbid  process,  so  well  and 
learnedly  described,  commenced  in  the  cortex  cerebri,  and  then 
descended  through  the  basal  ganglia  to  the  spinal  cord. 

Caizergues'  Case  of  Cerebral  Localisation.— Dr.  Caizer- 

gues,  in  a  pamphlet  of  eleven  pages,  which  first  appeared  in  the 
'  Montpellier  Medical,'  describes  a  case  of  cerebral  haemorrhage,  in 
which  the  new  views  as  to  the  functions  of  the  cortex  cerebri  and 
white  matter  of  the  centrum  ovale  are  well  illustrated.  The  man, 
38  years  of  age,  was  admitted  into  the  hospital  at  Montpellier  with 
mitral  contraction  and  insufficiency  and  contraction  of  the  aorta. 
The  arteries  were  believed  to  be  atheromatous.  Suffering  from 
diarrhoea  he  rose  from  his  bed,  and  returned  exclaiming,  "  I  cannot 
move  my  fist."  Then  a  feeling  of  tingling,  similar  to  what  he  had 
felt  in  the  arm,  appeared  in  the  right  leg,  and  ten  minutes  later 
the  whole  right  side  was  paralysed.  He  was  heard  to  say  to  the 
religieuse,  "  Ma  mere,"  and  these  were  the  last  intelligible  words 
he  was  heard  to  speak,  though  he  tried  to  make  himself  under- 
stood by  signs.  The  interne  ascertained  the  presence  of  hemi- 
anaesthesia  nicely  limited  to  the  right  side  of  the  body.  There  was 
no  trembling  or  convulsions.  He  died  about  three  hours  after  the 
first  attack.  An  effusion  of  blood  was  found  in  the  left  hemisphere, 
which  stretched  in  an  oblique  direction  from  above  downwards 
and  from  behind  forwards.  The  blood  had  raised  the  convolutions 
of  the  motor  zone  without  injuring  their  tissue,  and  had  gained  the 
surface  at  one  point  near  the  union  of  the  middle  and  upper  third 
of  the  ascending  parietal  (posterior  median  of  Ecker).  The  mass  of 
the  clot,  about  the  size  of  a  small  apple,  extended  obliquely  from 
below  the  fissure  of  Eolando  to  the  fissure  of  Sylvius.  Neither  the 
nucleus  lenticularis  nor  the  nucleus  caudatus  was  touched,  but  the 
internal  capsule  which  separates  them  was  found  destroyed  at  its 
posterior  and  external  part.  The  optic  thalamus  had  escaped 
injury. 

Dr.  Caizergues  thinks  that  the  blood  escaped  gradually  from  the 
giving  way  of  several  miliary  aneurisms.  He  holds  that  the 
paralysis  of  the  arm  and  then  of  the  leg  was  due  to  the  destruc- 
tion of  the  conducting  white  fibres  of  the  centrum  ovale,  and  not 
to  any  lesion  of  the  motor  area  of  grey  matter,  which  Dr.  Caizer- 
gues regards  as  left  uninjured,  although  the  blood  forced  its  way 
to  the  surface  at  one  point.  The  hemianaesthesia  is  explained  by 
the  destruction  of  the  internal  capsule  of  the  corpus  striatum,  and 


AND   FOREIGN   JOURNALS.  141 

the  aphasia  is  explained  hy  the  rupture  of  the  lower  pediculo- 
frontal  fibres. 

William  W.  Ireland. 

Lactic  Acid  as  a  Hypnotic— Dr.  Maragliano  has  recorded 
in  the  Hivista  Sjperimentale  di  Freniatria  (Anno  V.  Fascicolo  III.') 
the  result  of  some  experiments  upon  the  hypnotic  and  sedative  pro- 
perties of  lactic  acid  upon  the  insane.  He  mentions  two  theories 
upon  the  production  of  sleep.  Some  physiologists  have  advanced 
that  under  the  influence  of  fatigue  oxygen  disappears  from  the 
blood,  causing  inactivity  of  the  nervous  centres  and  sleep,  but 
the  provision  of  oxygen  being  renewed,  their  diminished  powers 
are  restored,  and  the  man  awakes.  Others  hold  that,  though  the 
quantity  of  oxygen  in  the  blood  is  not  less  during  sleep  than  during 
the  waking  state,  it  is  quickly  absorbed  by  those  materials,  such 
as  creatine  and  lactic  acid,  which  are  the  result  of  the  dis- 
integrating activity  of  the  bodily  organism,  and  which  require  to 
be  oxidised  ere  they  are  eliminated.  When  this  oxidisation  has 
been  accomplished,  the  brain  can  again  make  use  of  the  oxygen 
in  the  blood  and  resume  its  proper  functions. 

According  to  the  experiments  of  Eanke  and  Preyer,  the  artificial 
introduction  of  lactic  acid  and  other  products  of  retrograde  meta- 
morphosis are  capable  of  producing  weariness  and  sleep.  With  this 
theory  in  mind  a  number  of  German  physicians  used  lactate  of  soda 
or  lactic  acid  in  the  treatment  of  sleeplessness,  but  the  results  were 
somewhat  disappointing.  Doctors  Maragliano  and  Sepilli  tried  these 
drugs  in  about  a  hundred  cases  of  insanity.  They  found  that  if 
given  (lactic  acid  in  doses  of  8  to  10  grammes  and  lactate  of  soda 
12  to  15  grammes)  three  or  four  hours  before  bedtime,  they  were 
sufficient  to  subdue  the  insomnia  of  quiet  melancholia ;  but  they 
had  little  or  no  effect  if  given  immediately  before  going  to  bed. 
In  more  decided  cases  of  agitation  and  sleeplessness  they  were 
found  very  inferior  to  chloral  and  morphia,  besides  being  too  costly 
for  ordinary  use.  They  were  also  apt  to  produce  nausea  and 
vomiting. 

W.  W.  Ireland. 

Relations  of  Brain,  Mind,  and  Higher  Nerve  Function  — 

In  an  able  address  delivered  at  the  beginning  of  the  session  of  the 
Pathological  and  Clinical  Society  of  Glasgow,  Dr.  Alexander 
Kobertson  discusses  some  of  the  pathological  and  physiological 
relations  of  brain,  mind,  and  higher  nerve  function.     He  begins  by 


142  ABSTRACTS  OP   BRITISH 

giving  a  short  sketch  of  the  simpler  forms  of  nervous  apparatus  in 
the  lower  animals,  then  proceeds  to  consider  at  length  the  theory 
of  localisation  of  brain  function,  and  particularly  as  it  relates  to 
the  cerebral  convolutions,  "  how  far  it  seems  worthy  of  acceptance, 
and  how  far  it  seems  problematical."  An  epitome  of  physiological, 
pathological,  and  anatomical  evidence  in  support  of  the  theory  of 
localisation  is  then  gone  over,  from  which  it  may  be  gathered  that 
the  greatest  amount  and  most  important  part  of  the  evidence  is 
gained  from  a  study  of  pathology,  and  more  especially  from  the 
consideration  of  such  diseases  as  aphasia,  paralysis,  and  Jacksonian 
epilepsy. 

Next  in  importance  is  the  physiological  evidence,  in  which  some 
of  the  results  obtained  by  Ferrier  and  Hitzig  by  electrical  stimu- 
lation are  discussed.  Dr.  Robertson  says  that  of  course  there 
is  no  doubt  about  the  facts  elicited  by  these  observers.  It  is 
in  the  interpretation  of  these  facts  that  the  difficulty  lies;  that 
is,  whether  the  purposive  movements,  and  so  forth,  brought  about 
by  stimulation  of  the  cortex,  are  simply  due  to  conduction  of 
electrical  currents  from  the  grey  matter  of  the  surface  to  the 
basal  motor  ganglia;  or  depend  on  mere  conduction  of  electricity 
from  the  motor  centre  to  the  basal  ganglia  by  means  of  special 
fibres  for  the  particular  movements  induced ;  or  are  due  to  reflex 
action,  the  surface  in  the  area  of  the  apparent  motor  centres 
being  centripetal  or  afferent  to  the  corpus  striatum ;  or  again  are 
due,  as  Brown-Sequard  proposes,  to  inhibition ;  or,  lastly,  as  Hitzig 
himself  advocates,  to  "  what  may  be  called  a  sensory  explanation  " 
of  the  apparent  motor  centres. 

The  anatomical  evidence  referred  to  by  Dr.  Robertson  does  not 
call  for  special  reference,  but  he  is  of  opinion  that  on  the  whole  it 
leans  to  the  theory  of  localisation.  Dr.  Robertson  goes  on  to  say 
that  in  the  light  of  cortical  localisation  we  arrive  at  a  more  satisfac- 
tory explanation  of  many  forms  of  paralysis,  and  are  able  to  account 
better  for  the  grouping  of  symptoms  and  general  course  of  some 
other  forms  of  nervous  disease.  Take,  says  he,  the  case  of  general 
paralysis  of  the  insane.  In  this  disorder  psychical  disturbance 
usually  precedes  defective  articulation,  but  occasionally  they  begin 
simultaneously.  Now  the  presence  of  motor  centres  in  the  super- 
ficial grey  matter  affords  a  ready  solution  of  the  difficulty,  showing 
how  there  may  be  associated  two  kinds  of  symptoms  apparently  so 
different  from  each  other,  as  delusion  and  defective  articulation, 
but  really  so  closely  allied  since  the  motor  intuitions  of  language 
are  so  deeply  concerned  in   the  exercise  of  thought.     And  it  is 


AND   FOREIGN   JOURNALS.  143 

worthy  of  note  that  the  adhesion  of  the  pia  mater  to  the  con- 
volutions is  most  marked  in  the  frontal  and  parietal  regions,  a 
fact  which  supports  the  theory  of  localisation  so  far  as  it  applies 
to  motor  centres. 

The  hypothesis  of  the  psychical  and  motor  functions  being  in 
such  close  relation  also  goes  far  to  account  for  the  frequent  mani- 
festation of  motor  symptoms  in  other  forms  of  insanity. 

W.  G.  Thompson,  M.D. 

Traumatic  Insanity. — Dr.  Brower  {Chicago  Medical  Journal 
and  Examiner,  December  1879)  believes  that  the  production  of 
insanity  by  injury  to  the  head  probably  depends  less  on  the  nature 
of  the  injury  and  its  associated  phenomena  than  on  the  inherent 
peculiarities  of  the  individual.  Fatal  injury  to  the  brain  may 
result  from  sudden  violence  inflicted  on  the  skull  without  injury 
to  the  cranial  bones.  Dr.  Brower  had  under  observation  during 
the  late  rebellion  "  a  case  of  gunshot- wound  of  the  head,  that  in 
twenty  days  resulted  in  death,  and  post-mortem  examination  showed 
no  injury  to  the  cranial  bones,  but  an  abscess  in  the  brain  and 
associated  meningitis  and  encephalitis.  The  case  was  one,  doubt- 
less, of  contusion  of  the  brain  with  solution  of  continuity  of  its 
constituent  elements,  and  without  injury  to  the  bone,  the  skull 
undergoing  change  of  form  suddenly,  and  the  cerebral  substance 
offering  less  resistance  than  its  bony  covering,  extravasation  and 
laceration  of  brain-tissue  ensued."  This  author  believes  that  if  the 
connection  between  the  injury  and  a  criminal  act  is  complete,  "  the 
history  will  show  a  neurophatic  diathesis — will  show  that  after 
the  injury  cephalegia  was  frequent,  that  the  sleep  was  insufficient 
in  quantity,  or  else  disturbed  by  dreams;  that  after  a  time  change 
was  noticed  in  the  emotional  and  then  in  the  intellectual  part  of 
the  mind  ;  in  rare  cases  both  may  occur  simultaneously." 

Bullet-WOUnd  of  the  Brain.— Dr.  E.  F.  Brodie  records 
(American  Practitioner,  January  1880)  an  interesting  case  of  this 
form  of  injury.  A  man,  aged  22,  received  on  August  11,  1879,  a 
wound  of  the  cranium  from  a  pistol-ball.  The  ball,  which  weighed 
half-an-ounce,  entered  at  the  supra-orbital  foramen,  fractured  the 
orbital  roof  and  temporal  fossa,  passed  beneath  the  integument  to  a 
point  two  inches  and  a  fourth  above  the  meatus  auditorius  externus 
and  out,  dividing  the  posterior  branch  of  the  temporal  artery. 
Several  spiculae  of  bone  were  removed,  and  about  half-an-ounce  of 


144      ABSTRACTS  OF   BRITISH   AND   FOREIGN   JOURNALS. 

cerebral  tissue  issued  from  the  point  of  entrance.  The  patient  was 
semi-comatose  for  about  five  days.  On  the  tenth  day  he,  having 
been  kept  on  low  diet,  became  so  excessively  hungry  that  his  friends 
imprudently  allowed  him  to  eat  bread  and  bacon,  smoke  a  cigar, 
"  and  enjoy  a  convivial  round  generally,"  during  which  his  out- 
raged system  revolted.  He  had  haemorrhage  from  the  posterior 
branch  of  the  temporal  arteiy  to  the  extent  of  five  quarts.  The 
wounds  suppurated,  and  four  days  later  a  scale  of  lead,  weighing 
28  grains,  was  removed  from  the  roof  of  the  orbit,  and  also  several 
large  spiculae  of  bone.  In  six  weeks  the  wounds  closed,  leaving  no 
symptoms  beyond  slight  impairment  of  memory  and  stiffening  of 
the  muscles  of  the  jaw.  Subsequent  observation  of  this  case  would 
be  interesting  and  instructive. 

Robert  Lawson,  M.B. 


BEAIN. 

JULY,  1880. 

Original  ^rtkles. 

ON  THE  FORM  AND  TOPOGRAPHICAL  RELATIONS 
OF  THE  CORPUS  STRIATUM. 

BY   PROFESSOR   J.   C.   DALTON,   NEW   YORK. 

In  the  annals  of  the  Anatomical  and  Surgical  Society  of 
Brooklyn,  New  York,  for  January,  1880,  I  gave  a  resume  of 
the  main  features  of  structure  of  the  brain,  as  now  generally 
understood  by  cerebral  anatomists,  together  with  a  special 
description  of  the  corpus  striatum.  These  two  subjects  have  a 
necessary  connection  with  each  other,  since  the  corpus  striatum 
is  found,  on  examination,  to  reproduce  very  nearly  the  general 
curvilinear  arrangement  of  the  cerebral  convolutions.  The 
description  here  given  of  its  special  configuration  is  mainly 
in  the  form  of  a  transcript  from  my  former  article. 

If  we  leave  out  of  consideration  for  the  present  the  cere- 
bellum and  some  of  the  smaller  collections  of  grey  matter  in 
the  cerebrum,  the  structure  of  the  cerebro-spinal  axis,  accord- 
ing to  the  ideas  now  in  vogue,  may  be  simply  described  as 
follows  : — The  grey  matter  of  the  spinal  cord,  surrounding  its 
central  canal,  is  continued  upward  on  the  floor  of  the  fourth 
ventricle  and  around  the  aqueduct  of  Sylvius.  This  con- 
tinuous layer  is  the  "  grey  matter  of  the  medullary  canal," 
and  from  it  all  the  cerebro-spinal  nerves  of  motion  and  general 
sensibility  take  their  origin.  It  is  connected  by  longitudinal 
tracts  of  white  substance  with  the  parts  above ;    and   these 

VOL.   III.  l 


146  ON  THE   FOEM  AND   TOPOGRAPHICAL 

longitudinal  tracts,  under  the  name  of  the  crura  cerebri,  reach 
a  second  division  or  deposit  of  grey  matter  at  the  base  of  the 
brain,  known  as  the  corpus  striatum  and  optic  thalamus,  or  the 
"  cerebral  ganglia."  The  ascending  fibres  of  white  substance 
pass  through  and  between  these  ganglia  in  the  form  of  a  fan- 
shaped  layer,  the  "  internal  capsule ;"  and  from  its  upper 
border  they  emerge  into  the  diverging  expansion  of  the  corona 
radiata,  to  reach  finally  the  third  and  largest  mass  of  grey 
matter,  which  is  spread  out  in  the  convolutions  of  the  cortex. 

In  this  diagrammatic  schedule  of  the  structure  of  the 
encephalon  many  things  of  course  are  omitted ;  such  as 
the  transverse  commissures,  connecting  similar  parts  of  the 
two  hemispheres,  and  the  antero-posterior  tracts,  connecting 
different  parts  of  the  same  hemisphere.  The  question  whether 
some  fibres  of  the  crus  cerebri  and  internal  capsule  may  not 
be  continuous,  from  the  spinal  cord  to  the  cerebral  convolu- 
tions, is  also  left  untouched.  But  for  our  present  purpose  the 
above  account  will  represent  sufficiently  well  the  relations  of 
the  white  and  grey  matter  in  the  cerebro-spinal  system. 

The  spinal  nerves  and  nerve-roots  connect  the  peripheral 
organs  with  the  grey  matter  of  the  medullary  canal.  The 
columns  of  the  cord  and  the  crura  cerebri  connect  this  nervous 
centre  with  the  cerebral  ganglia ;  and  from  the  cerebral 
ganglia  the  fibres  of  the  internal  capsule  and  corona  radiata 
are  the  organs  of  transmission  to  the  cerebral  convolutions. 
Thus  the  intermediate  station  or  deposit  of  grey  matter, 
between  the  cerebral  convolutions  above  and  the  spinal  cord 
below,  consists  of  the  corpus  striatum  and  the  optic  thalamus. 

Of  these  two  bodies  the  optic  thalamus  is  the  more  homo- 
geneous in  appearance,  since  the  white  fibres  which  penetrate  it 
rapidly  separate  from  each  other,  giving  to  the  ganglion  a 
comparatively  uniform  light  grey  tint.  The  whole  of  the 
thalamus,  furthermore,  lies  on  the  median  side  of  the  internal 
capsule.  On  the  other  hand,  in  the  corpus  striatum  the  fibres 
run,  for  the  most  part,  in  distinct  bundles  to  within  a  short 
distance  of  its  outer  border,  giving  it  the  visibly  striated 
appearance  to  which  it  owes  its  name.  Moreover,  this  gan- 
glion is  split  almost  completely  into  two  portions  by  the 
internal  capsule,  which  lies  between  them.     As  the  internal 


RELATIONS  OF   THE   CORPUS   STRIATUM. 


147 


capsule  is  directed  obliquely  from  below  upward  and  from 
within  outward,  one  portion  of  the  ganglion  lies  inside  and 
above  it,  the  other  outside  and  below  it.  The  former  is  the 
intraventricular  portion,  or  that  which  is  visible  from  the 
cavity  of  the  lateral  ventricle.  It  has  a  club-shaped  ex- 
tremity, or  head,  directed  forward,  and  a  slender  continuation, 
or  tail,  directed  backward  ;  whence  its  name  of  the  "  caudate  " 


Fig.  1. — Diagram  of  Brain  in  Transverse  Vertical  Section. 


1. 

Cms  cerebri. 

F'. 

First  frontal  convolution. 

2. 

Internal  capsule. 

F". 

Second  frontal  convolution. 

3. 

Optic  thalamus. 

F'" 

.  Third  frontal  convolution. 

4. 

Corpus  striatum. 

T'. 

First  temporal  convolution. 

5. 

Surcingle. 

T". 

Second  temporal  convolution. 

L.N. 

Lenticular  nucleus. 

T'" 

.  Third  temporal  convolution. 

S. 

Fissure  of  Sylvius. 

H. 

Gyrus  hippocampi. 

Fo. 

Gyrus  fornicatus. 

nucleus.  The  other  portion,  not  being  visible  from  the  ven- 
tricle, but  covered  by  the  internal  capsule  and  imbedded  in 
the  substance  of  the  brain,  is  known  as  the  extraventricular 
portion  ;  or,  from  its  lens-like  figure,  the  "  lenticular  "  nucleus. 
It  is  now  customary  to  confine  the  term  "  corpus  striatum  "  to 
the  first  or  intraventricular  portion  of  the  ganglion.     This  is 

L  2 


148  ON   THE   FORM   AND  TOPOGRAPHICAL 

the  part  to  which  my  observations  especially  refer,  and  which 
I  shall  describe  under  the  name  of  corpus  striatum.  The 
remaining  portion  is  designated  only  as  the  "  lenticular 
nucleus." 

The  relations  of  the  parts  above  enumerated  may  be  shown 
by  a  vertical  and  transverse  section  of  the  brain,  as  in  Fig.  1. 
This  figure  is  a  diagrammatic  one,  but  it  indicates  the  general 
direction  of  the  fibres  of  the  crus  cerebri,  the  internal  capsule, 
and  the  corona  radiata.  It  is  also  seen  that  both  the  optic 
thalamus  and  the  corpus  striatum  are  above  and  on  the  inner 
side  of  the  internal  capsule,  while  the  lenticular  nucleus  is 
outside  and  below  it.  This  nucleus,  as  is  well-known,  is 
divided  by  thin  laminae  of  white  substance  into  three  nearly 
concentric  layers  or  zones. 


Fig.  2. — Bkain  of  Fox  (Profile  View). 

The  outer  surface  of  the  brain,  on  the  other  hand,  formed 
by  the  convolutions  of  the  cortex,  is  directly  connected  with 
central  ganglia.  The  external  configuration  of  the  hemisphere 
shows  that  all  its  convolutions  are  grouped  round  a  point 
corresponding  with  the  internal  capsule  and  the  lenticular 
nucleus.  This  is  most  distinctly  visible  in  such  a  brain  as 
that  of  the  fox  (Fig.  2),  which  is  marked  only  by  a  few  simple 
and  parallel  convolutions.  The  constant  and  deeply  marked 
fissure  of  Sylvius  runs  upward  and  backward,  forming  the  line 
of  division  between  the  frontal  and  temporal  lobes;  and  all 
the  convolutions  on  the  convexity  of  the  hemisphere  are 
curved  very  regularly  around  this  fissure.  They  run  upward 
and  backward  in  front  of  it,  encircle  its  upper  extremity,  and 
then  return  downward  and  forward  to  the  end  of  the  temporal 


KELATIONS   OF   THE   CORPUS  STRIATUM.  149 

lobe.  The  entire  brain  has  the  appearance  of  being  folded, 
with  all  its  convolutions,  about  a  transverse  axis  passing 
through  the  bottom  of  the  fissure  of  Sylvius. 

In  the  human  brain,  Fig.  3,  the  fissure  of  Sylvius  is  equally 
distinct,  and  it  is  easy  to  see  the  same  general  arrangement 
of  the  convolutions  running  round  its  upper  extremity.  The 
three  frontal  convolutions  pass  upward  and  backward  on  the 
convexity  of  the  hemisphere,  and  the  three  temporal  convo- 
lutions run  downward  and  forward,  as  in  the  fox,  beneath  the 


Fig.  3. — Human  Brain  (Profile  View). 

S'.   Fissure  of  Sylvius,  anterior  branch.    R.  Fissure  of  Rolando. 
S".  Fissure  of  Sylvius,  posterior  branch.    P.  Interparietal  fissure. 

fissure  of  Sylvius.  But  in  the  human  brain,  as  compared 
with  that  of  the  animal,  there  are  two  new  features.  In  the 
first  place,  the  fissure  of  Sylvius  is  double.  There  is  an 
anterior  branch  and  a  posterior  branch,  and  included  between 
them  is  a  triangular-shaped  portion  known  as  the  "  operculum." 
Secondly,  in  addition  to  the  fissure  of  Sylvius,  and  above  it  in 
position,  there  is  another  deep  fissure,  running  in  a  nearly 
vertical  direction  from  above  downward,  on  the  side  of  the 
hemisphere.  This  is  the  fissure  of  Rolando.  It  is  accom- 
panied by  two  convolutions  having  a  similar  direction,  one 
in  front  and  one  behind,  the  "  anterior  and  posterior  central 


150  ON   THE   FORM  AND  TOPOGRAPH ICAL 

convolutions."  The  fissure,  with  its  accompanying  convolu- 
tions, seems  to  cut  across  the  general  direction  of  the  curvature 
nearly  at  right  angles,  and  consequently  to  introduce  a  certain 
degree  of  confusion  into  the  plan  of  the  cerebral  hemisphere. 
But  this  is  only  an  appearance.  It  is  due  simply  to  the 
greater  development,  in  man,  of  the  cortical  substance. 

At  the  bottom  of  the  Sylvian  fissure,  the  side  of  the  brain 
is  occupied  by  the  convolutions  of  the  insula,  or  "  island 
of  Beil."  The  insula  corresponds  in  position  with  the  outer 
surface  of  the  lenticular  nucleus,  and  it  is  that  part  of  the 
cortex  of  the  brain  which  is  in  most  immediate  proximity 
to  the  cerebral  ganglia.  Externally  it  is  concealed  from 
view,  because  that  portion  of  the  cerebral  hemisphere  included 
between  the  two  branches  of  the  Sylvian  fissure  projects  down- 
ward from  above,  and  overhangs  it  like  a  cover.  It  is  for 
that  reason  this  portion  is  named  the  "  operculum;"  and  when 
the  two  branches  of  the  Sylvian  fissure  are  opened,  and  the 
operculum  between  them  lifted  up,  the  insula,  with  its 
convolutions,  is  exposed  at  the  bottom  of  the  cavity. 

It  is  evident,  therefore,  that  the  fissure  of  Eolando  is  not 
really  an  interruption  to  the  general  run  of  the  convolutions. 
In  the  fox  the  fissure  of  Sylvius  is  single,  and  the  convo- 
lutions are  folded  upon  themselves  only  once.  But  in  man 
the  fissure  of  Sylvius  is  double,  and  the  convolutions  are 
folded  upon  themselves  twice.  The  development  of  the  cortex 
in  the  human  brain  is  so  great  that  different  parts  of  it  over- 
lap each  other.  The  operculum  hangs  down  over  the  insula. 
The  longitudinal  convolutions,  instead  of  running  in  a  con- 
tinuous curve  from  before  backward,  make,  about  the  middle 
of  their  course,  an  additional  crook.  They  turn  downward 
along  the  anterior  branch  of  the  Sylvian  fissure,  and  again 
upward  along  its  posterior  branch.  In  that  way  they  form 
the  operculum.  The  anterior  and  posterior  central  convolu- 
tions are  the  parts  immediately  folded  upon  each  other  in  this 
downward  angular  bend ;  and  the  dividing  line  between  them 
is  the  fissure  of  Eolando. 

The  median  surface  of  the  hemisphere,  Fig.  4,  shows  a 
very  similar  arrangement  of  its  convolutions;  the  central 
one,  known  as  the  "  gyrus  fornicatus,"  being  continued,  in  an 


RELATIONS   OF   THE   COKPUS   STRIATUM.  151 

arched  or  vaulted  form,  around  the  end  of  the  crus  cerebri, 
the  internal  capsule,  and  the  cerebral  ganglia.  It  starts 
from  the  inferior  part  of  the  anterior  lobe,  just  in  front  of  the 
Sylvian  fissure.  It  turns  up  round  the  anterior  extremity  of 
the  corpus  callosum,  and  runs  along  its  upper  border.  Here 
it  is  included  between  the  corpus  callosum  below  and  the 
fissura  calloso-marginalis  above.  It  extends  backward,  in  this 
part  of  its  course,  as  a  single  independent  convolution,  as 
far  as  the  ascending  branch  of  the  fissura  calloso-marginalis. 
There  it  makes  one  or  two  connections  with  the  precuneus, 


Fig.  4. — Human  Bbain;  Median  Subface  op  the  Right  Hemisphere. 


A. 

First  frontal  convolution. 

T. 

Third  temporal  convolution. 

F. 

Gyrus  fornicatus. 

c.  c. 

Corpus  callosum. 

1'. 

Paracentral  lobule. 

1. 

Fissura  calloso-marginalis. 

Q. 

Lobulus  quadratus,  or  Prsecuneus. 

2. 

Fissura  parieto-occlpltalis. 

c. 

Cuneus. 

3. 

Fissura  calcarina. 

0',  0".  Occipito-temporal  convolutions. 

and  farther  back  with  the  cuneus  also.  It  then  curves  round 
the  posterior  extremity  of  the  corpus  callosum,  passes  beneath 
the  crus  cerebri,  and  runs  downward  and  forward  to  a  point 
just  behind  the  fissure  of  Sylvius,  almost  exactly  opposite 
the  place  from  which  it  started.  In  this  lower  portion  of  its 
course  it  is  often  designated  as  the  "  gyrus  hippocampi ;"  and 
it  in  fact  forms  the  hippocampus  major  by  the  inflection  of  its 
grey  matter  in  the  inferior  horn  of  the  lateral  ventricle. 

The  final  destination,  therefore,  of  the  fibres  of  the  internal 
capsule   and  the   corona  radiata  is  the   grey  matter  of  the 


152  ON   THE   FORM  AND   TOPOGRAPHICAL 

cortex.  That  part  of  the  cortex  nearest  the  cerebral  ganglia 
is  the  insula  ;  and  all  the  rest  of  the  cerebral  convolutions  are 
arranged,  in  a  more  or  less  continuous  curve,  around  this  spot. 
All  these  points  are  tolerably  well  known,  and  receive  the 
general  assent  of  anatomists  who  have  paid  particular  attention 
to  the  brain. 

But  there  are  some  features  in  the  form  and  topographical 
relations  of  the  corpus  striatum  which  are  not  so  well  under- 
stood. By  the  term  corpus  striatum,  as  already  mentioned, 
we  now  designate  only  the  intraventricular  nucleus  of  the 
ganglion,  or  that  which  lies  above  and  on  the  inside  of  the 
internal  capsule.  It  is  usually  described  as  consisting  of  a 
thick  or  club-shaped  portion  directed  forward,  and  a  slender 
tail-like  extremity  directed  backward,  which  runs  along  the 
outer  edge  of  the  lateral  ventricle,  and  terminates  somewhere 
about  the  posterior  border  of  the  optic  thalamus.  In  reality 
it  is  much  more  extensive  than  this.  A  few  writers  speak 
of  it  as  reaching  into  or  to  the  inferior  horn  of  the  ventricle  ; 
but  the  only  ones,  so  far  as  I  know,  who  have  described  it  in 
a  really  satisfactory  way  are  Gratiolet,  Todd,  and  Ludovic 
Hirschfeld.  The  best  account  of  all  is  that  given  by  Gratiolet, 
in  his  '  Anatomie  comparee  du  Systeme  nerveux,'  published 
in  1857.  This  description  is  generally  ignored  by  present 
writers,  and  it  is  expressly  stated  by  so  high  an  authority  as 
Henle,  in  his  last  edition,  1879,  that  the  tail-like  process  of 
the  corpus  striatum  "  tapers  gradually  from  before  backward, 
and  terminates  in  a  point  opposite  the  end  of  the  optic 
thalamus."  ('Handbuch  der  Nervenlehre,'  Braunschweig, 
1879,  p.  155.) 

On  the  contrary,  the  real  form  of  the  corpus  striatum  is 
almost  that  of  a  complete  ring.  This  can  often  be  seen 
quite  distinctly,  without  further  preparation,  when  the  lateral 
ventricle  has  been  opened  completely  from  the  inside,  as  in 
Fig.  5.  The  slender  continuation  of  the  corpus  striatum  may 
then  be  traced,  throughout  its  course,  by  the  pinkish-grey 
colour  of  its  substance,  showing  through  the  transparent 
lining  of  the  ventricle.  The  body  of  the  corpus  striatum 
grows  smaller  as  it  extends  backward  in  the  upper  part  of  the 
ventricle,  and  soon  runs  into  the  well-known  tail-like  pro- 


RELATIONS   OF   THE   CORPUS   STRIATUM. 


153 


longation.  This  prolongation  reaches  the  posterior  end  of 
the  optic  thalamus,  curves  downward  into  the  inferior  horn 
of  the  ventricle,  and  then  runs  forward  again  to  the  anterior 
extremity  of  the  inferior  horn.  It  thus  encircles  the  crus 
cerebri  and  internal  capsule  with  a  narrow  band  of  grey 
matter,  like  a  loop  or  surcingle ;  it  ends  below  in  the  inferior 
horn  of  the  ventricle,  almost  exactly  opposite  the  point  where 
it  started  in  the  anterior  horn,  and  it  repeats,  within  the 
cavity  of  the  ventricle,  the  same  folded  or  curvilinear  arrange- 


Fig.  5. — Longitudinal  and  Vertical   Section  of   the  Right  Hemisphere, 
showing  Cavity  op  Lateral  Ventricle  (seen  from  the  Inner  Side). 

C.  Corpus  striatum.    S.  Surcingle.    V.  Ventricle.    A.  Amygdala.    1.  Fissura  parieto-occipi talis. 

2.  Fissura  calcarina. 

ment  that  is  to  be  seen  in  the  gyrus  fornicatus  and  in  the 
convolutions  of  the  cortex  generally. 

The  head  of  the  corpus  striatum  is  not  only  connected  with 
the  lenticular  nucleus,  but  also  with  the  grey  matter  at  the 
base  of  the  brain,  just  in  front  of  the  Sylvian  fissure.  The 
extremity  of  the  surcingle,  on  the  other  hand,  is  connected 
with  a  deposit  of  grey  matter  forming  the  anterior  wall  of  the 
inferior  horn  of  the  ventricle.  This  grey  mass  is  known  as 
the  "  amygdala."  It  is  sometimes  spoken  of  as  an  independent 
nucleus,  but  it  is  really  continuous  with  the  convolutions  of 
the  base  of  the  brain,  immediately  behind  the  fissure  of 
Sylvius. 


154  ON   THE   FORM   AND  TOPOGRAPHICAL 

In  a  view  of  the  ventricle  opened  from  the  inner  side  it 
is  seen  that  the  curved  prolongation,  or  "surcingle,"  of  the 
corpus  striatum  is  not  of  the  same  size  throughout.  It 
diminishes  considerably  in  thickness  while  approaching  the 
end  of  the  optic  thalamus,  then  increases  somewhat  during 
its  downward  curvature,  again  becomes  more  slender,  and 
finally  terminates  at  the  front  part  of  the  inferior  horn,  in 
a  visibly  enlarged  extremity.  Very  often,  but  not  always, 
it  is  more  or  less  interrupted  near  this  enlarged  portion  by  one 
or  two  bundles  of  white  fibres,  which  cross  it  obliquely  from 
above  downward.  These  fibres  come  from  the  lower  portion  of 
the  taenia  semicircularis.  The  taenia  semicircularis  is  well 
known,  in  the  upper  part  of  the  ventricular  cavity,  as  a  slender 
ribbon  of  white  substance,  running  from  before  backward 
along  the  floor  of  the  ventricle,  between  the  optic  thalamus  on 
the  inside,  and  the  corpus  striatum  on  the  outside.  It  ac- 
companies everywhere  the  concave  border  of  the  surcingle, 
following  the  same  curvature  downward  into  the  inferior  horn 
of  the  ventricle,  then  runs  forward  along  the  roof  of  the  in- 
ferior horn  to  its  anterior  end,  and  there  terminates  in  the 
amygdala.  It  is  a  little  before  this  termination  that  some  of 
its  fibres  are  seen  to  cross  the  grey  matter  of  the  surcingle. 

The  reason  why  this  annular  form  of  the  corpus  striatum  is 
not  more  easily  recognized  in  brain  sections  is  that  its  two 
parts  are  so  distant  from  each  other  and  so  variable  in  size. 
If  a  vertical  and  transverse  section  of  the  brain  be  made  some- 
what in  front  of  the  anterior  commissure,  it  will  show  the  head 
of  the  corpus  striatum,  in  that  situation,  of  very  large  size. 
In  a  similar  section,  passing  behind  the  anterior  commissure 
and  through  the  front  part  of  the  optic  thalamus,  the  corpus 
striatum  will  appear  smaller ;  and  in  one  passing  through  the 
middle  of  the  optic  thalamus  it  will  be  smaller  still.  It  there 
begins  to  present  the  cut  surface,  not  of  the  head  of  the  corpus 
striatum,  but  of  its  tail-like  appendage.  If  we  continue  to 
make  sections  farther  and  farther  back,  the  appendage  will  at 
last  disappear,  and  this  disappearance  will  happen  about  the 
time  the  sections  pass  the  posterior  end  of  the  optic  thalamus. 
It  is  this  fact,  no  doubt,  which  has  led  to  the  belief  that  the 
corpus  striatum  comes  to  an  end  about  the  same  region.    But 


RELATIONS   OF    THE    CORPUS   STRIATUM.  155 

in  reality  it  has  not  done  so.  It  has  curved  downward  in  the 
space  left  between  two  successive  sections,  and  has  entered  the 
inferior  horn  of  the  ventricle,  to  run  forward  towards  its  ter- 
mination in  the  amygdala.  Sometimes  a  section  will  happen 
to  strike  exactly  the  plane  of  curvature  of  this  part,  and  will 
then  show  a  more  or  less  elongated  tract  of  grey  matter, 
running  from  above  downward,  a  little  to  the  outside  of  the 
optic  thalamus.  In  a  transverse  section  of  the  brain,  through 
the  middle  of  the  optic  thalamus,  the  caudate  portion  of  the 
corpus  striatum  is  visible  above  the  internal  capsule  and 
lenticular  nucleus  (Fig.  1,  4).  But  there  is  also  a  smaller 
isolated  area  of  grey  matter  below  the  level  of  the  lenticular 
nucleus,  and  near  the  outer  part  of  the  inferior  horn  of  the 
ventricle  (Fig.  1,  5).  Now  these  two  sections,  one  above  the 
internal  capsule,  and  one  below  it,  are  the  same  thing,  or 
rather  they  are  two  different  parts  of  the  same  thing.  One  of 
them  is  that  part  of  the  corpus  striatum  which  occupies  the 
floor  of  the  lateral  ventricle  above,  the  other  is  that  which 
runs  along  the  roof  of  the  inferior  horn  below.  In  every 
section  behind  this,  both  these  two  parts  will  be  visible,  until 
a  point  is  reached  a  little  beyond  the  optic  thalamus,  when 
they  will  both  disappear  together. 

The  same  figure  shows  how  other  parts  of  the  brain,  which 
are  arranged  in  a  looped  form,  may  appear  twice  in  a  vertical 
section.  In  the  brain  of  the  fox  (Fig.  2)  it  is  evident  that  a 
section  made  at  right  angles  to  the  fissure  of  Sylvius  would 
cut  the  frontal  convolutions  in  front  of  this  fissure,  and  also, 
the  temporal  convolutions,  in  reverse  order,  behind  it.  In 
Fig.  1  the  same  thing  appears  in  the  human  brain.  The 
frontal  convolutions  above  the  Sylvian  fissure  correspond  in 
number  with  the  temporal  convolutions  below  it.  In  the 
parietal  region  their  direct  continuity  is  interrupted  by  the 
downward  curvature  about  the  fissure  of  Eolando  ;  but  still  it 
is  perfectly  evident  that  the  first  temporal  convolution  (T')  is 
really  the  end  of  the  third  frontal  (F"'),  the  second  temporal  (T") 
of  the  second  frontal  (F"),  and  the  third  temporal  (T'")  of  the 
first  frontal  (F').  The  remaining  convolution  of  the  temporal 
lobe,  the  gyrus  hippocampi  (H),  is  the  termination  of  the  gyrus 
fornicatus  (Fo).     In  Fig.  4  the  curvature  of  this  convolution 


156 


ON   THE   FORM  AND   TOPOGRAPHICAL 


is  shown  throughout  its  length.  It  is  plain  that,  in  a  vertical 
section  passing  through  the  middle  portion  of  the  brain,  it 
would  be  cut  twice ;  once  above  and  once  below  the  situation 
of  the  cerebral  ganglia. 

It  is  not  very  easy  to  make  a  longitudinal  section  of  the 
brain  which  shall  pass  continuously  through  the  whole  of  the 
ring,  or  loop,  formed  by  the  corpus  striatum  and  the  surcingle. 
All  parts  of  the  loop  are  not  exactly  in  the  same  plane,  either 
vertically  or  longitudinally.     Its  posterior  portions  are  situated 


Fig.  6. — Longitudinal  and   Vertical  Section  of  the   Right  Hemisphere, 
through  Corpus  Striatum  and  Surcingle  (seen  from  the  Inner  Side). 


F.  Frontal  lobe. 
0.  Occipital  lobe. 
T.  Temporal  lobe. 
C.  Corpus  striatum. 


S.  Surcingle. 

cc.  Part  of  corpus  callosum. 
1,  2.  Middle  and  internal  zones  of  lenticular  nucleus. 
3.  Diverging  fibres  of  internal  capsule. 


farther  from  the  median  line  than  the  anterior,  and  its  superior 
and  inferior  branches  are  so  slender  and  so  widely  separated 
that  it  is  difficult  to  make  a  single  oblique  cut  which  shall 
show  the  whole  of  both.  It  can  be  done,  however,  by  following 
carefully  with  the  edge  of  a  knife  the  curved  track  of  grey 
substance  from  point  to  point,  until  the  whole  of  it  is  exposed, 
and  then  removing  the  adjacent  white  substance  down  to  the 
same  level.     Such  a  section  is  shown  in  Fig.  6. 

It  has  exposed  the  white  surface  and  radiating  structure  of 


RELATIONS   OF   THE   CORPUS   STRIATUM.  157 

the  internal  capsule,  and  near  its  centre  a  little  of  the  in- 
ternal and  middle  zones  of  the  lenticular  nucleus.  Surrounding 
the  capsule  is  the  grey  tract  of  the  corpus  striatum  and  sur- 
cingle. In  the  head  of  the  corpus  striatum  the  bundles  of 
white  fibres  are  visible,  traversing  the  grey  matter  in  the  form 
of  distinct  streaks,  or  striations,  to  within  a  short  distance  of 
its  outer  border.  In  the  slender  curved  portion,  on  the  other 
hand,  no  striations  are  to  be  seen,  the  colour  being  everywhere 
of  a  uniform  grey.  But  throughout  this  region  the  radiating 
fibres  of  the  internal  capsule  pass  beneath  the  band  of  grey 
substance  obliquely,  from  without  outward,  in  the  form  of 
distinct  bundles  ;  and  between  these  bundles  the  grey  matter 
of  the  surcingle  dips  down,  more  or  less  deeply,  at  irregular 
intervals. 

It  is  for  this  reason  that  transverse  sections  of  this  part  of 
the  corpus  striatum  vary  so  much  in  apparent  size.  If  the  cut 
happen  to  pass  through  a  projecting  bundle  of  the  internal 
capsule,  the  section  of  the  surcingle  will  appear  small.  If  it 
pass  in  the  interval  between  two  bundles,  the  area  of  grey 
matter  exposed  will  be  considerably  larger.  From  the  same 
cause  the  sections  are  often  unequal  on  the  two  sides  of  the 
brain.  The  projecting  bundles  of  the  internal  capsule  and 
the  gaps  between  them  seldom  correspond  exactly  in  the 
right  and  left  hemispheres  ;  and  if  they  did,  we  could  hardly 
make  a  section,  either  horizontal  or  transverse,  which  should 
follow  with  entire  precision  the  same  plane  on  the  two  sides. 
But,  notwithstanding  these  apparent  inequalities  and  variations, 
the  grey  matter  is  continuous  throughout  the  curved  portion 
of  the  corpus  striatum. 

In  horizontal  sections  of  the  brain,  the  size  and  form  of  the 
cerebral  ganglia  vary  greatly  according  to  the  level  at  which 
the  section  is  made.  At  the  level  of  the  corpus  callosum  only 
a  little  of  the  arched  portion  of  the  corpus  striatum  is  ex- 
posed, and  none  of  the  lenticular  nucleus  is  visible.  Some- 
what below  this,  at  the  level  of  the  fornix,  the  arched  portion 
of  the  corpus  striatum  disappears,  but  there  is  a  large  oval 
section  of  its  head  in  front,  and  a  small  one  of  a  surcingle 
behind.  Lower  still  the  lenticular  nucleus  comes  into  view, 
separated  from  the  head  of  the  corpus  striatum  by  the  dis- 


158  ON   THE   FORM   AND   TOPOGRAPHICAL 

tinctly  marked  anterior  prolongation  of  the  internal  capsule. 
At  the  level  of  the  anterior   commissure,  as  in  Fig.  7,  the 


Fig.  7. — Horizontal  Section  of  the  Brain,  through  the  Anterior  Commissure 
and  LowEit  Part  op  the  Cerebral  Ganglia  (from  a  Photograph). 

a,  a.  Head  of  corpus  striatum.      6,  b.  Surcingle. 

lenticular  nucleus  and  the  head  of  the  corpus  striatum  begin 
to  fuse  with  each  other,  owing  to  the  partial  disappearance  of 
the  internal  capsule  between  them.     At  this  level  the  head  of 


KELATIONS   OF   THE   COEPUS   STRIATUM.  159 

the  corpus  striatum,  a,  a,  is  much  reduced  hi  size  and  altered 
in  shape.  The  lenticular  nucleus  occupies  a  position  outside 
and  behind  it ;  and  still  farther  back,  at  b,  b,  is  the  section  of 
the  surcingle,  which  is  here  beginning  to  run  downward  and 
forward,  along  the  roof  of  the  inferior  horn  of  the  ventricle. 
At  a  lower  section  still,  the  head  of  the  corpus  striatum  would 
be  united  with  the  cortical  convolutions  in  front  of  the  Sylvian 
fissure,  and  the  surcingle  with  the  grey  substance  of  the 
amygdala. 


NYSTAGMUS. 


BY   R.   P.   OGLESBY, 


Ophthalmic  and  Aural  Surgeon  to  the  Leeds  General  Infirmary.     Late  Lecturer  on 
Pathology  in  the  Leeds  School  of  Medicine. 

Nystagmus  is  the  name  of  a  disease  arising  from  various 
causes  of  a  distinct  and  separate  character — difficult  of  gene- 
ralisation— causes  diametrically  opposite — causes  which  on  the 
one  hand  lead  to  grave  results,  on  the  other  hand  simple,  but 
lasting  in  duration. 

That  it  is  a  disease  worthy  of  careful  study  is  doubtless  true, 
and  if  symptomatic  cases  of  varied  origin  are  met  with,  then  it 
always  repays  the  trouble  of  careful  investigation. 

I  have  primarily  classed  the  disease  under  two  heads — the 
idiopathic  and  the  symptomatic,  and  afterwards  redivided 
them  into  local  and  central. 

The  idiopathic  form  of  nystagmus  depends  on  a  defective 
co-ordination  of  the  associated  movements  of  the  eye,  of  a 
character  essentially  simple  in  form  and  not  portending  any 
grave  result. 

The  oscillation  of  the  eyeball  varies  in  kind  and  degree.  It 
may  be  horizontal  (this  is  the  most  frequent  form  met  with), 
or  rotary,  the  eyeballs  oscillating  round  the  axis  of  the  oblique 
muscles.  The  vertical  form  is  seldom  met  with,  the  only  case 
I  have  seen  occurred  in  a  man  suffering  from  disease  of  the 
nervous  centres. 

It  is  recorded  that  binocular  vision  and  nystagmus  are  in- 
compatible, and  truly  so  in  the  majority  of  cases ;  but  where 
vision  in  either  eye  is  but  slightly  impaired,  the  muscular 
apparatus  not  very  unstable,  the  two  eyes  can  act  perfectly 
together  during  strong  convergence. 

The   disease   is   peculiar  to   infant    life   consequent   upon 


NYSTAGMUS.  161 

various  congenital  abnormalities.  It  is  also  due  in  infant  life 
to  peculiar  constitutional  defects  which  early  show  themselves. 
Idiopathic  nystagmus  is  usually  permanent,  its  causes  being 
as  a  rule  irremediable.  It  will  be  well  to  glance  at  the  local 
form  of  the  disease  named  congenital,  and  subdivide  as 
follows : — 

1st.  Albinoes. — A  very  interesting  form  of  the  disease  occurs 
in  Albinoes.  Marked  examples  of  the  kind  were  shown  by 
me  at  a  meeting  of  the  West  Riding  Medico-Chirurgical 
Society.  The  subjects  are  two  little  boys — brothers — aged 
6  and  8  years.  Their  hair  is  of  a  brilliant  white;  and 
their  eyes,  as  they  moved  from  member  to  member  in  the 
powerfully  gaslighted  room,  oscillated  horizontally  with  great 
rapidity.  The  family  history  disclosed  physiological  pecu- 
liarities concerning  the  child-bearing  propensities  of  the 
mother.  In  these  cases  the  unstable  condition  of  the  muscular 
apparatus  is  caused  by  absence  of  the  hexagonal  pigment  cells 
of  the  choroid. 

2nd.  Cataract. — Lamellar  or  zonular  cataract  does  not  gene- 
rally cause  blindness.  The  marginal  portion  of  the  lens  is 
sufficiently  clear  to  allow  rays  of  light  to  penetrate.  Nys- 
tagmus usually  accompanies  this  form  of  lens  mischief. 

3rd.  Choroiditis. — Choroiditis  is  generally  the  result  of  in- 
herited syphilis,  and  is  by  far  the  most  prolific  source  of 
congenital  mischief  which  causes  nystagmus. 

4th.  Anomalies  of  Refraction. — Viz.  myopia,  hypermetropia, 
and  astigmatism,  are  seldom  accompanied  by  a  nystagmus. 
Once  or  twice  in  myopes  I  have  noticed  this  condition,  but  in 
these  cases  the  ophthalmoscope  disclosed  an  advanced  disease 
of  the  choroid. 

IDIOPATHIC   NYSTAGMUS,   ACQUIRED. 

1st.  Opacities. — On  the  surface  of  the  cornea  which  implicate 
a  large  portion  of  the  area  of  the  pupil.  In  these  cases  it  is 
necessary  for  vision  that  the  eyes  should  perform  rapid 
horizontal  movements  to  bring  the  image  rays  to  a  focus  on 
the  retina. 

2nd.  Sympathetic. — A  young  mau   was  admitted  as   an  in- 

VOL.   III.  M 


162  NYSTAGMUS. 

patient  under  my  care  for  treatment.  His  case,  a  somewhat 
novel  one,  presented  peculiarities  worth  recording.  In  his 
youth  he  had  lost  the  sight  of  the  right  eye  from  suppuration 
of  the  cornea,  the  result  being  a  shrunken  globe.  Two  years 
ago  he  sought  the  aid  of  a  notorious  quack  who  practises 
ophthalmology.  (?)  This  man  persuaded  him  to  wear  a  glass  eye 
over  the  diseased  globe.  When  first  seen  by  me  he  was  still 
wearing  the  glass  eye,  which  had  produced  a  condition  of 
sympathetic  ophthalmia  in  the  left  eye.  The  pupil  was 
partially  closed,  and  vision  limited  to  shadows.  After  dis- 
pensing with  the  glass  eye,  I  removed  the  shrunken  globe 
with  great  benefit,  as  vision  in  the  left  eye  at  once  improved. 
In  this  case  there  was  a  very  decided  nystagmus  of  the 
rotatory  kind. 

With  regard  to  the  acquired  form  of  idiopathic  nystagmus, 
examples  might  with  ease  be  multiplied,  but  the  two  cases 
given  are  sufficient  to  show  how  injury  or  disease  will 
cause  it. 

The  treatment  varies  much,  and  is  at  the  best  but  of  little 
good.  In  some  cases  tenotomy  has  been  vaunted  as  a  cure.  I 
am  afraid  it  is  a  proceeding  of  doubtful  value.  In  such  cases  as 
are  met  with  in  Albinoes,  coloured  glasses  often  prove  useful ; 
and  should  the  nystagmus  depend  on  an  anomaly  of  refraction 
— a  thing  very  rare — properly  selected  glasses  are  of  value. 

The  prognosis  of  idiopathic  nystagmus  is  simple,  and  may 
be  summed  up  in  but  few  words.  It  is  seldom  dangerous  and 
but  rarely  cured. 

SYMPTOMATIC   NYSTAGMUS. 

Having  glanced  thus  briefly  at  the  idiopathic  form  of  the 
disease,  I  must  say  a  few  words  regarding  a  much  more  serious 
form,  usually  named  Symptomatic  Nystagmus.  In  the  first 
form  we  have  unstable  muscular  action,  due  to  local  causes, 
not  interfering  with  the  general  health  of  the  patient,  and 
being  more  unpleasant  than  dangerous. 

In  the  latter  form  we  have  a  disease  of  central  origin,  often 
grave  in  its  prognosis,  and  either  due  to  unstable  grey  matter, 
such  as  that  which  will  produce  the  petit  mal,  or  a  form  much 


NYSTAGMUS.  163 

more  serious,  as  in  myelitis  or  disseminated  sclerosis.  By  far 
the  greater  proportion  of  cases  depends  upon  a  condition  of  irri- 
tation rather  than  direct  structural  lesion,  and  by  far  the  greater 
proportion  of  cases  lasts  over  a  period  indefinite  in  time,  so 
far  as  clinical  observation  teaches  us.  In  many  instances  the 
symptoms  occur  in  early  life  and  after  an  acute  attack,  often 
so  severe  as  to  endanger  life,  subside  and  remain  passive  for  a 
time,  afterwards  to  break  out  afresh,  and  so  end  in  the  patient's 
death.  Again,  nystagmus  may  be  the  early  and  most  pro- 
minent symptom  of  undoubted  intra-cranial  mischief,  of  a  kind 
that  runs  its  course  quickly  and  early  destroys  life.  In  these 
cases  the  patients  are  invariably  young,  and  in  many  instances 
the  lesion  is  due  to  acute  inflammation  of  the  base  (basilar 
meningitis). 

The  etiology  of  nystagmus  has  many  bearings.  In  some  cases 
the  actual  nervous  lesion  is  the  sequela  of  acute  febrile  attacks. 
Typhoid  fever  is  not  unfrequently  followed  by  serious  visual 
ailments,  chiefly — so  far  as  my  experience  goes — by  neuro- 
retinitis,  and  less  frequently  by  nystagmus,  the  two  represent- 
ing a  cerebral  lesion  consequent  upon  the  acute  meningitis 
during  the  fever.  Acute  rheumatism  is  another  cause  of  the 
disease.  Especially  is  it  caused  by  those  cases  in  which 
valvular  disease  of  the  heart  is  present.  Severe  and  long- 
continued  mental  troubles  associated,  in  the  poor,  with  great 
privation  and  often  absolute  want  of  food.  A  case  of  this 
kind  is  at  present  under  my  care. 

In  one  case  the  early  cause  was  severe  mental  trouble  con- 
cerning the  payment  of  a  large  sum  of  money.  The  patient, 
who  had  a  very  sensitive  and  highly  organised  nervous  system, 
completely  broke  down  under  the  strain.  Symptoms  of  dis- 
seminated sclerosis  followed,  nystagmus  after  some  months 
appearing  and  becoming  persistent. 

The  worst  form  of  nystagmus  I  have  as  yet  seen  is  persistent 
in  a  boy  aged  10  years,  and  is  congenital.  The  nervous 
system  is  ailing  generally,  and  the  whole  symptoms  very 
undoubtedly  point  to  insular  sclerosis,  due,  I  believe,  to 
inherited  syphilis. 

Pathology  points  to  the  following  lesions  as  a  cause  of 
symptomatic  nystagmus  : — 

M  2 


164  NYSTAGMUS. 

1st.    Lesions  of  sub-ventricular  origin. 

2nd.  Lesions  affecting  medulla  oblongata. 

3rd.  Lesions  specially  affecting  grey  matter  of  floor  of  fourth 

ventricle. 
4th.  Basilar  meningitis. 
5th.  Miliary  tubercle  (meninges). 
6th.  Wounds  of  brain  and  medulla. 
7th.  Haemorrhage  (cerebral). 

Epilepsy  plays  a  marked  part  in  the  cause  of  symptomatic 
nystagmus,  and  in  many  cases  the  oscillation  of  the  eyeballs  is 
constant.  This,  so  far  as  my  experience  teaches  me,  is  never 
seen  except  in  those  who  suffer  from  the  minor  form  of  the 
disease.  In  epileptics  suffering  from  the  graver  form  of  the 
disease,  the  movements  of  the  globes,  although  in  character 
the  same  as  in  the  minor  form,  are  not  persistent — commencing 
and  ending  with  the  fit. 

A  remarkable  case  of  epilepsia  gravior  associated  with 
nystagmus  occurred  in  a  boy  aged  13  years,  who  was 
suddenly  disabled  by  a  sunstroke.  When  first  seen  by  me 
as  an  infirmary  patient,  he  was  having  as  many  as  ten  fits  a 
a  day.  The  aura  was  most  distinct,  commencing  in  the  right 
arm  and  passing  upwards  along  the  neck  towards  the  eye. 
This  was  followed  by  diplopia,  and  the  seizure — rotatory  nys- 
tagmus— always  occurred  during  the  paroxysm.  Large  doses  of 
bromide  of  potassium,  given  thrice  daily,  after  administration 
for  a  fortnight,  produced  a  most  beneficial  effect  on  the  character 
and  the  number  of  the  fits.  After  taking  the  bromide  for 
twelve  months  he  reported  himself  as  cured.  This  was  not 
really  so,  for  after  the  lapse  of  three  months  he  again  attended 
as  an  out-patient,  saying  that  he  had  been  quite  free  from  the 
attacks  till  the  week  previous,  since  which  time  he  had  had 
three.  He  again  attended  for  three  weeks,  and  at  the  end  of 
that  period  he  assured  me  he  was  quite  well,  and  I  have  not 
seen  him  since — now  six  months  ago.  In  this  case  bromide  of 
potassium,  in  20-grain  doses  given  three  times  a  day,  was  the 
sole  treatment,  and  the  dose  was  never  increased,  neither  was 
the  drug  given  in  combination  with  either  digitalis  or  bella- 
donna.    Although  rotatory  nystagmus  was  most  marked  during 


NYSTAGMUS.  165 

each  paroxysm,  the  unstable  condition  was  manifestly  governed, 
so  to  speak,  by  the  exhibition  of  the  drug,  and  at  last  cured. 

Another  case  of  epilepsy  associated  with  nystagmus  equally 
interesting  is  worth  recording.  During  the  year  1873,  I 
admitted  as  an  in-patient  a  delicate,  strumous-looking  boy,  who 
complained  of  failing  sight.  He  had  horizontal  nystagmus, 
and  the  ophthalmoscope  disclosed  hyperemia  of  the  discs 
with  venous  stasis.  His  chief  symptoms  were  continuous 
bilious  vomiting,  dilated  pupils,  and  occasionally  a  curious 
nervous  discharge,  unlike,  in  general  character,  a  true  epilepsy. 
Grave  doubts  were  entertained  with  regard  to  his  recovery, 
acute  tubercular  meningitis,  or  tumour  of  base,  being  sus- 
pected. Under  rigid  treatment  he  recovered,  and  at  the  ex- 
piration of  three  months,  vision,  which  during  the  attack  had 
materially  suffered,  returned.  I  have  now  to  relate  the  most 
interesting  point  of  the  case.  On  the  10th  day  of  April  of  the 
present  year  this  patient,  now  an  adult,  consulted  me  privately 
for  confirmed  epilepsy,  giving  the  following  details  : — 

After  leaving  the  Hospital  in  1873,  he  remained  apparently 
quite  well  until  the  spring  of  '78,  when,  from  no  apparent 
cause,  he  began  to  decline  in  health,  lose  flesh,  and  become 
nervous.  This  was  followed  by  cerebral  neuralgia  of  an  inten- 
sified form,  which  was  in  turn  superseded  by  epilepsia  gravior. 
The  paroxysms  are  described  as  very  severe,  occurring  at 
intervals  five  times  daily.  When  under  treatment  for  the 
earlier  illness  as  a  boy,  the  nystagmus  was  but  slight ;  now 
it  is  most  marked.  The  length  of  time  which  elapsed  between 
the  first  and  second  illness,  the  unstable  condition  of  grey 
matter  lying  dormant  for  so  long  a  period,  in  readiness  to 
again  depart  from  its  normal  (healthy)  functions  from  a  cause 
difficult  in  this  instance  to  define,  renders  the  case  one  of  more 
than  ordinary  interest. 

In  the  form  of  minor  epilepsy  which  characterised  the  early 
seizures  of  this  boy,  may  we  not  infer  that,  though  the  cells 
were  not  in  an  actually  diseased  state,  it  was  but  a  condition 
— a  departure  from  healthy  life — which  portended  ulterior 
disease  ?  Then  again,  as  in  this  example,  how  many  cases  of 
petit  mal  pass  into  the  graver  form  without  eliciting  but  a 
passing  notice  ?     I  believe  many  more  than  we  suspect. 


166  NYSTAGMUS. 

It  has  never  been  my  lot  to  diagnose  the  earliest  changes 
in  grey  matter  which  ultimately  lead  to  epilepsia  gravior ; 
but  I  suspect  that  were  it  possible  to  recognise  such  change — 
that  is,  so  soon  as  the  cells  gave  the  slightest  evidence  of 
abnormal  function — urgent  and  well-directed  treatment  might 
be  of  such  service  as  to  end  in  the  permanent  health  of  the 
unstable  matter.  This  is  more  or  less  evidenced  by  the 
case  I  relate  of  continuous  bilious  vomiting,  with  nervous 
discharges,  which,  although  apparently  cured,  remained  latent 
for  years,  ultimately  to  break  out  afresh  and  merge  into 
the  graver  form  of  epilepsy.  Here,  although  the  nervous 
discharges  were  frequent  in  the  earlier  illness,  yet  it  is  pro- 
bable that  the  unstable  condition  of  the  grey  matter  was  not 
advanced,  and  therefore  the  attacks  were  mild.  Is  it  not 
possible,  if  the  disease  during  these  early  stages  remains 
unchecked,  that  the  number  of  cells  having  a  perverted 
function  seriously  increase  until  a  large  area  of  grey  matter 
becomes  involved? 

Whilst  jotting  down  notes  for  this  paper,  I  was  fortunate 
to  meet  with  a  case  in  which  I  truly  believe  the  earliest 
symptoms  of  this  form  of  disease  were  diagnosed.  Three 
weeks  ago  I  was  asked  by  a  medical  friend  to  see  with  him  a 
lady  who  was  suffering  from  the  following  symptoms.  Sudden 
sensations  as  of  a  weight  being  placed  at  the  commencement 
of  the  spine  immediately  beneath  the  occiput.  This  feeling 
of  weight  lasted  for  a  few  seconds,  and  was  succeeded  by  a 
violent  throbbing,  "  trembling  of  the  blood,"  she  called  it ; 
then  came  flashes  of  light,  rotary  nystagmus,  and  a  sudden 
falling  forwards  of  the  body,  the  fall  being  saved  by  seizing 
some  article  of  furniture.  Although  entire  unconsciousness 
never  took  place,  yet  so  soon  as  the  body  fell  forwards,  there 
was  an  irresistible  feeling  to  lie  flat  on  the  back.  After 
remaining  in  the  hdrizontal  posture  for  ten  or  fifteen  minutes 
the  paroxysm  passed  away,  to  recur  again  in  a  few  hours. 
The  history  was  as  follows.  Very  healthy  and  strong  till  a 
year  ago,  she  then  passed  through  a  severe  scarlet  fever. 
Ever  since  convalescence  from  that  disease  these  nervous 
discharges  had  shown  themselves,  and  latterly  with  increasing 
severity.     There  had  been  on  several  occasions  haemorrhage 


NYSTAGMUS.  167 

from  the  bowel ;  but  as  the  system  never  suffered  from  it,  and 
the  general  habit  of  the  body  was  inclined  to  corpulency  and 
the  face  somewhat  flushed,  I  did  not  consider  it  a  factor  in  the 
production  of  these  nervous  discharges,  much  to  my  medical 
friend's  astonishment,  who  came  armed  to  the  consultation 
with  that  idea.  He  said  he  had  carefully  watched  the  case 
from  the  beginning,  and  it  was  a  nervous  system  deprived  of 
proper  nourishment  from  that  cause.  I  found  the  treatment 
had  been  chiefly  iron  and  ammonia,  which,  taken  in  large 
doses,  appeared  to  aggravate  the  symptoms  most  unpleasantly. 
Thirty  grains  of  bromide  of  potassium,  with  30-drop  doses  of 
tincture  of  digitalis,  taken  early  before  rising  and  late  before 
retiring  for  the  night,  had  a  magical  effect,  the  third  dose 
subduing  all  the  worst  symptoms,  and  its  continuance — thus 
far — keeping  the  patient  in  perfect  health.  This,  I  take  it, 
was  a  case  of  the  first  degree.__Here,  I  think,  undoubtedly 
we  had  the  earliest  departure  from  healthy  nervous  action, 
the  merest  instability  of  nerve-cells  which,  left  without  appro- 
priate treatment,  would  have  passed  on  to  grave  functional 
disturbance  and  so  on  to  epilepsy. 

I  have  mentioned  a  case  of  disseminate  sclerosis  with 
nystagmus,  and  as  disseminated  sclerosis  is,  as  a  rule,  followed 
at  a  late  date  by  nystagmus,  I  must  relate  the  history  of  a 
case  now  under  my  care. 

Five  or  six  years  ago  a  gentleman  of  very  active  business 
habits  suffered  a  serious  loss  which  produced  unusual  mental 
grief,  so  much  so  that  business  was  entirely  neglected,  and  his 
family,  as  it  were,  deserted.  His  wife,  who  has  great  faculty 
for  detail,  assured  me  that  for  the  whole  of  their  previous 
married  life  he  had  shown  unimpaired  nervous  energy,  and 
was  known  to  his  friends  and  acquaintances  as  a  man  of  more 
than  ordinary  stamina.  Eighteen  months  after  his  business 
loss,  his  wife  noticed  that  there  was  a  slight  dragging  of  the 
lower  extremities  and  a  decided  uncertainty  of  gait.  This 
symptom  gained  ground  but  slowly,  and  is  not  now  very 
serious.  The  upper  extremities  were  next  affected.  This 
paresis  of  the  limbs  remained  for  a  long  time  as  the  only 
sign  of  disease  going  on  in  the  spinal  cord,  and  as  it  made  but 
slow  progress,  his  family  were  in  hopes  that  he  might  recover. 


168  NYSTAGMUS. 

This  was  not  to  be.  Thirteen  months  after  the  first  symptoms 
of  paralysis,  his  wife  noticed  that  he  had  a  laboured  manner  of 
enunciation  which  slowly  grew  worse.  She  expressed  it  as 
"  taking  great  pains  to  utter  each  word  distinctly."  Diplopia 
— transient  at  first,  afterwards  of  a  more  permanent  character 
— brought  him  under  my  care.  Nystagmus  was  not  then 
present,  nor  did  it  occur  until  some  time  afterwards.  The 
nystagmus,  transient  and  feeble  at  first,  is  now  persistent  and 
marked.  In  this  case  there  is  considerable  interference  with 
the  retinal  circulation,  the  discs  being  white  with  diminished 
calibre  of  arteries,  and  considerable  dilatation  of  veins.  Con- 
cerning the  ophthalmoscopic  appearances  in  nystagmus,  I  shall 
say  more  hereafter.  The  very  gradual  invasion  of  the  nervous 
centres  in  this  case  renders  it  probable  that  a  lengthened  period 
will  elapse  ere  a  fatal  termination  arrives. 

An  interesting  fact  remains  to  be  noticed  concerning  the 
apparent  atrophy  of  the  optic  discs.  To  all  apparent  observa- 
tion, it  would  seem  as  if  from  invasion  of  the  optic  tracts 
or  chiasma,  total  destruction  of  nerves  had  resulted,  and 
so  total  abolition  of  function.  As  a  rule,  this  is  not  the 
case,  arising  from  the  fact  that  only  a  portion  of  the  nerve 
suffers  from  a  sclerosed  patch.  In  other  cases,  the  whole 
nerve  apparently  suffers,  but  not  microscopically  so,  the 
medullary  sheath  having  alone  suffered,  leaving  the  axis- 
cylinder  intact. 

To  the  fact  that  atrophy  (apparent)  of  the  optic  disc  is  not 
correlated  with  total  abolition  of  function  in  all  cases,  I  have, 
in  years  gone  by,  drawn  attention.  Vide  papers  by  me  in  the 
'  Lancet,'  '  Ophthalmic  H.  Reports,'  and  '  Dublin  Quarterly 
Journal  of  Medical  Science.' 

At  that  time  pathological  investigation  had  not  thrown 
sufficient  light  on  the  subject  for  me  to  state,  without  fear  of 
contradiction,  why  one  apparently  atrophied  disc  should  be 
associated  with  complete  visual  loss ;  whilst  another,  differing 
in  no  wise,  so  far  as  the  ophthalmoscopic  appearances  went, 
should  suffer  but  slightly,  and  vision  be  sufficient  for  ordinary 
purposes. 

That  disseminated  sclerosis  in  a  large  number  of  cases  is 
followed    by  nystagmus   is   beyond   doubt,  as   evidenced    by 


NYSTAGMUS.  169 

the  writings  of  Charcot,  Moxon,  and  others.1  I  have  seen,  I 
believe,  but  four  such  cases.  These  cases  but  rarely  come 
within  the  range  of  ordinary  ophthalmic  practice ;  and  as  the 
nystagmus  is  a  symptom  which  manifests  itself  during  the  late 
stages  of  the  disease,  we  miss  seeing  a  number  of  interesting 
cases  which  would  afford  valuable  clinical  instruction. 

The  inability  to  regulate  visual  co-ordination  arises  from 
many  causes,  but  from  none  more  so  than  direct  injury  to 
the  medulla  oblongata.  Many  years  ago  a  gentleman,  to 
all  appearance  enjoying  robust  health,  whilst  performing  one 
of  nature's  functions,  horrified  the  female  who  suffered  his 
embraces  by  suddenly  rolling  on  his  side  speechless.  In 
less  than  half  an  hour  from  the  seizure  I  was  with  him.  The 
prominent  symptoms  were  stertorous  breathing  and  horizontal 
nystagmus,  with  widely-dilated  pupils  and  distended  palpebral 
orifices.  In  this  case  there  had  been  sudden  bleeding  from 
a  large  vessel,  and  considerable  destruction  of  tissue  in  the 
medulla.  Unfortunately,  the  injured  part  was  not  obtained 
for  further  examination,  so  that  the  more  exact  lesion  could 
not  be  determined. 

A  similar  case  to  the  above  occurred  some  years  ago,  and 
from  a  similar  cause.  This  brain  was  preserved,  and  is  now, 
I  believe,  in  our  Medical  School.  The  injury  in  this  case  was 
also  destruction  of  tissue  in  the  medulla  from  haemorrhage. 

Another  case  of  a  similar  character,  but  if  possible  more 
interesting,  occurred  in  the  case  of  a  lady  now  resident  in  this 
town.  During,  as  she  believed,  perfect  health,  she  suddenly 
fell  down  comatose  whilst  performing  some  household  duty. 
When  first  seen  by  me  her  symptoms  resembled  in  every 
particular  those  of  the  case  first  related,  with  the  exception 
that  the  nystagmus  was  transient,  occurring  at  intervals  of 
five  and  ten  minutes,  and  lasting  for  varying  periods  of  from 
ten  to  forty  seconds,  the  horizontal  movements  of  the  eyes 
being  violent  in  manner  from  the  way  in  which  the  muscles 
acted.  In  consultation  with  one  of  my  hospital  colleagues,  it 
was  decided  to  bleed  freely.  This  was  done  to,  say  the  extent 
of  sixteen  ounces,  with  a  benefit  very  extraordinary ;  for  while 

1  Consult   an   interesting   paper   by   Dr.   Moxon,   'Guy's  Hospital   Reports,' 
3rd  Series,  vol.  xx.  '  Insular  Sclerosis  of  the  Brain  and  Spinal  Cord.' 


170  NYSTAGMUS. 

yet  the  blood  flowed,  the  coma  passed  away,  the  nystagmus 
ceased,  and  immediate  danger  was  averted.  Although  there 
was  a  slight  relapse,  the  symptoms  recurred  in  a  minor  degree, 
the  patient  recovered,  and  perfect  convalescence  resulted. 

A  case  of  injury  to  the  medulla  oblongata,  followed  by 
nystagmus,  is  ably  reported  in  the  '  Medico  -  Chirurgical 
Transactions,'  vol.  xlvi.,  1863,  by  Dr.  Waters.  A  young  man 
received  a  severe  blow  on  the  left  side  of  the  face,  followed  by 
dilated  pupils  and  nystagmus.  The  following  day  he  walked 
to  the  hospital.  Although  he  presented  no  very  urgent  symp- 
toms, he  suddenly  expired  the  day  following.  A  blood-clot 
occupied  one  portion  of  the  medulla,  and  the  right  restiform 
body  was  lacerated.  The  grey  matter  of  the  floor  of  the  fourth 
ventricle  was  also  involved.  This  case  illustrates  how  serious 
a  lesion  of  the  nervous  centres  may  be  without  causing  promi- 
nent objective  symptoms. 

I  must  mention  a  certain  form  of  nervous  disorder  which  I 
have  had  occasion  to  treat  on  six  separate  occasions,  two  of  the 
cases  showing  marked  diplopia  and  nystagmus. 

The  first  case  which  I  saw  occurred  ten  years  ago,  and  the 
patient,  an  engineer,  is  still  under  my  care.  The  symptoms, 
although  approaching  in  character  those  which  we  frequently 
meet  with  in  minor  epilepsy,  are,  when  analysed,  different  in 
degree.  Until  lately  I  have  been  puzzled  to  name  this 
disease,  and  have  been  content  to  term  it  "  cerebral  pulsa- 
tion." The  six  cases  I  have  seen  occurred  in  men.  The  first 
was  a  civil  engineer,  the  second  a  timber  merchant,  the  third 
a  man  constantly  engaged  in  literature,  the  fourth  a  general 
merchant,  the  fifth  a  clergyman,  and  the  sixth  a  medical  man  in 
a  large  general  practice.  I  mention  the  occupation  of  these 
men  to  show  that  the  employment  of  each  was  one  requiring 
brain  work,  and  that  of  considerable  strain  in  each  case.  I  am 
not  now  referring  to  that  form .  of  passive  cerebral  congestion 
which  is  almost  daily  met  with  in  over-worked  business  men, 
easily  cured  by  rest  and  quiet  and  change  of  scene;  but  a 
condition,  the  nature  of  which  in  many  particulars  resembles 
the  minor  epilepsy,  although  totally  different  in  others. 

Notes  of  the  first  case  seen  furnish  me  with  the  following 
particulars : — Mr.   C,    aged    37,   engaged    as    the    principal 


NYSTAGMUS.  171 

draughtsman  in  the  office  of  a  firm  of  civil  engineers,  in  con- 
sequence of  a  large  foreign  order,  had  been  drawing  plans  for 
many  hours  each  day  for  several  months.  The  success  of  the 
contract  depended  upon  his  skill,  and  as  his  father  was  one  of 
the  partners  in  the  firm  he  represented,  it  made  him  doubly 
anxious  to  succeed.  Naturally  of  a  nervous  temperament,  the 
strain  was  too  much,  and  one  day,  when  passing  from  the  office 
to  the  workroom,  he  was  seized  with  sudden  giddiness,  and  for 
a  moment  unconsciousness.  Neglecting  such  a  warning,  he  still 
pursued  his  usual  avocations,  until  a  paroxysm  more  serious 
demanded  medical  aid.  On  visiting  the  patient  I  found  a 
small  man  with  a  well-knit  frame,  and  what  was  quite  unusual 
to  his  ordinary  appearance  as  of  six  months  previous,  a  face 
swollen  and  flushed. 

He  gave  the  following  history  : — "  For  months  I  have  had 
a  growing  fulness  about  the  brain,  as  if  the  blood-vessels  were 
too  small  for  their  contents,  and  that  the  blood  was  endeavour- 
ing to  find  an  outlet  and  the  vessels  were  determined  not  to 
accommodate  themselves  to  this  new  state  of  things."  He  had 
frequent  hallucinations  and  impaired  memory,  the  latter 
ailment  being  a  great  source  of  trouble,  as  he  was  frequently 
forgetting  where  he  had  deposited  certain  papers  of  importance, 
and  otherwise  doing  unbusiness-like  acts.  It  is  hardly 
necessary  to  mention  that  with  such  cerebral  plethora  he  had 
constant  headache.  Another  peculiar  symptom  which  alarmed 
him  was  that  he  suddenly  fell  forward  when  walking  (this  gene- 
rally occurred  soon  after  leaving  an  omnibus  or  railway  carriage 
in  which  he  had  been  journeying),  but  always  managed  to 
save  the  fall,  by  seizing  hold  of  some  adjacent  object. 

On  many  occasions  these  seizures  were  associated  with  un- 
consciousness, and  always  with  horizontal  nystagmus.  The 
inability  to  regulate  his  visual  co-ordination  would  often  last 
for  many  seconds  after  consciousness  returned,  and  was  a 
perpetual  source  of  annoyance  to  him,  chiefly  from  the  fact 
that  many  of  those  who  had  witnessed  the  paroxysm  assured 
him  that  it  must  have  been  a  real  fit, "  for  your  eyes  rolled 
from  side  to  side."  Other  than  a  disinclination  for  food,  and 
a  somewhat  impaired  digestion,  I  could  not  detect  any  dis- 
turbance of  organs.     The  heart  was  apparently  healthy,  but 


172  NYSTAGMUS. 

the  arteries  were  hard  and  tortuous,  having  evidently  under- 
gone change  which  materially  affected  the  circulation  generally, 
as  evidenced  by  the  sudden  fits  of  unconsciousness,  due  no 
doubt  to  cerebral  haemorrhage. 

One  peculiarity  in  the  case  was  that  he  suffered  from 
traumatic  stricture  of  the  urethra — not  a  bad  one,  but 
sufficient  to  annoy  him,  and  require  the  passing  of  a  metallic 
bougie  monthly.  He  had  an  idea  that  the  cerebral  congestion 
was  worse  immediately  before  the  time  expired  for  the  passing 
of  the  bougie.  The  further  history  of  the  case  proved  that 
this  was  not  so.  One  curious  phenomenon  was  a  nervous 
discharge  through  the  retinas  of  a  series  of  bright  flashes,  as 
he  described  "  just  as  if  a  number  of  matches  had  been  struck 
one  after  the  other  within  the  eyes."  Examined  with  the 
ophthalmoscope,  the  optic  discs  were  markedly  hypersemic,  the 
veins  enormously  distended  and  tortuous,  and  a  condition  of 
arteries  seldom  seen,  they  being  hardly  discernible  from  the 
veins,  as  if  they  were  carrying  venous  blood,  and  also  being 
of  a  calibre  so  large  as  to  almost  deceive  you  into  the  belief 
that  they  were  actually  veins  much  distended. 

The  habits  of  the  patient  were  strictly  sober  in  all  things, 
and  he  had  never  contracted  syphilis.  As  medicine  and  rest 
proved  of  little  avail,  I  desired  the  advice  of  my  friend  Dr. 
Crichton-Browne,  then  of  the  West  Eiding  Asylum,  who  agreed 
with  me  that  the  disease,  although  resembling  the  less  serious 
form  of  epilepsy,  was  not  really  that  disease.  As  the  treat- 
ment adopted  after  consultation  did  not  prove  curative,  I  at 
last  persuaded  him  to  journey  through  the  United  States  and 
Canada.  The  effect  of  the  sea  voyage  was  very  remarkable, 
and  he  returned  all  but  convalescent.  By  strict  care  and 
frequent  rest  the  attacks  did  not  recur  more  than  once  in  six 
months.  He  has  just  passed  through  a  rather  severe  one 
which  confined  him  to  the  house  and  bed  for  four  days.  I 
have  but  little  doubt  the  paroxysms  would  resume  their  old 
frequency  and  virulence  should  he  again  return  to  constant 
employment. 

The  other  case  in  which  nystagmus  was  present  occurred  in 
a  general  merchant  whose  habits  were  vicious,  and  whose  con- 
stitution had   undergone   much    wear   and  tear.      This   case 


NYSTAGMUS.  173 

differed  from  the  last  in  an  important  point.  The  hallucina- 
tions of  the  first  patient  were  harmless.  In  this  patient's  case 
they  assumed  a  dangerous  form.  Watching  and  restraint 
alone  prevented  him  doing  bodily  mischief  to  his  wife,  who 
for  the  time  the  cerebral  congestion  remained  was  an  object  of 
extreme  hatred. 

Another  cause  other  than  excessive  mental  strain  is  a  dys- 
peptic condition  of  a  low  type.  The  ill-nourished  nervous 
matter  from  impurity  of  blood  is  probably  an  early  factor  in 
the  production  of  the-  disease.  I  feel  convinced  from  the 
lengthened  character  this  disease  generally  assumes,  and  its 
not  being  very  amenable  to  treatment,  that  it  may  become  an 
entity — a  disease  which  from  its  symptoms  and  duration  will 
find  a  place  amongst  the  ordinary  nervous  derangements  of 
authors.  An  analogous  form  of  the  disease  has  been  described 
as  cerebral  hyperemia  by  Dr.  Milner  Fothergill  in  the  West 
Eiding  Asylum  Eeports,  by  Dr.  Hamilton  of  New  York 
('  Nervous  Diseases,  their  Description  and  Treatment,'  1878), 
and  lately  by  Dr.  William  Hammond  of  New  York.  A  con- 
dition of  the  retina  is  noticed  by  the  last  writer  upon  which  I 
have  always  laid  great  stress  in  these  and  somewhat  similar 
cases.  There  is  a  condition  of  passive  congestion  more  or  less 
always  present,  and  a  peculiar  arterial  fulness — such  as  I  have 
just  described — which  is  rarely  observed  in  ordinary  cases. 
Another  abnormal  condition  of  the  retinal  circulation  is  the  ex- 
treme tortuosity  of  the  vessels,  an  appearance  which  would  lead 
one  to  infer  a  diseased  condition  of  the  arteries  of  the  brain. 

I  must  now  pass  on  to  describe  a  form  of  nystagmus  with 
which  I  have  long  been  familiar,  and  which  I  have  described 
elsewhere.  This  form  of  the  disease  I  have  designated 
"  Miners'  nystagmus,"  from  the  fact  that  it  occurs  in  men 
following  the  occupation  of  colliers.  In  giving  a  general 
description  of  this  form  of  the  disease,  I  cannot  do  better  than 
extract  from  my  former  paper  on  the  subject  a  few  preliminary 
remarks : 

On  a  Peculiar  Form  of  Nystagmus. 

"  The  history  and  symptoms  differ  but  little  in  the  cases 
already  observed,  but  a  fact  worthy  of  special  note  is,  that  all  the 


174  NYSTAGMUS. 

patients  as  yet  examined  are  by  occupation  colliers.  The  disease 
is  ushered  in  by  no  premonitory  symptoms,  is  persistent,  not 
amenable  to  treatment,  and  usually  occurs  after  the  age  of 
twenty-one.  Further  than  the  oscillation  of  the  globes,  which  is 
usually  a  horizontal  one,  no  trace  of  disease — either  local  or  con- 
stitutional— can  be  found.  The  eyes  are  normal  in  shape  and 
colour,  the  pupils  act  well,  and  the  muscular  movements  are 
performed  naturally,  when  the  body  is  in  the  erect  posture. 
One  peculiar  feature  of  the  disease  is  the  influence  which  the 
position  of  the  body  has  over  it.  In  the*  stooping  posture — the 
position  of  a  miner  when  at  work — the  oscillation  of  the  globes 
occurs ;  as  soon  as  the  body  is  erect,  the  eyes  cease  their  un- 
natural movements.  Family  history  does  not  point  to  the  in- 
heritance of  cerebral  disease.  Syphilis  is  not  a  factor  in  any  one 
of  the  cases.  The  urine  is  healthy,  the  eyes  present  no  oph- 
thalmoscopic appearances  of  disease,  and  the  power  of  vision 
is  perfect.  In  some  patients  the  globes  oscillate  as  soon  as 
evening  advances,  but  this  is  an  unfrequent  symptom.  I  was 
at  first  impressed  with  the  idea  that  pigmentation  of  the  retina 
lay  at  the  root  of  the  mischief,  but  no  single  case  under  my 
care  has  presented  any  disease  of  that  structure.  The  follow- 
ing is  the  history  of  one  case.  The  patient  describes  the  com- 
mencement of  the  very  first  attack  he  ever  had  thus  :  •  I  was 
stooping  at  work,  being  quite  well  in  health,  and  my  eyesight 
good,  when  suddenly  the  light  from  my  lamp  appeared  to  be 
moving  to  and  fro,  and  objects  became  indistinct.  When  I 
stood  up,  the  sight  returned.  This  peculiar  condition  has 
always  since  occurred,  when  I  have  stooped  to  begin  work ; 
and  my  eyes  have  rolled  from  side  to  side  so  long  as  I  have 
continued  with  my  body  bent.  As  soon  as  I  stood  erect,  the 
rapid  movements  of  the  eyes  ceased,  and  clearness  of  sight 
returned.' 

"  This  man  I  purposely  admitted  as  an  in-patient  to  watch 
his  case,  and  try  various  kinds  of  treatment.  Iron,  strychnine, 
arsenic,  quinine,  and  other  drugs  were  taken  without  the 
slightest  benefit.  He  was  therefore  made  an  out-patient  at 
the  end  of  six  weeks."1 

For  several  years  after  the  publication  of  this  paper  I  had 

1  '  British  Medical  Journal,'  Jan.  3,  1874. 


NYSTAGMUS.  175 

seen  but  few  of  these  cases.  I  am  indebted  to  the  kindness  of 
our  present  House  Physician,  Dr.  Barrs,  for  having  lately  trans- 
ferred to  my  care  several  cases  of  this  disease. 

During  my  early  investigations  into  the  nature  and  cause  of 
this  singular  and  interesting  disease,  I  was  much  struck  with 
the  fact  that  each  case  appeared  to  be  the  exact  counterpart  of 
its  fellow,  that  the  disease  occurred  without  apparent  cause, 
and  the  pathological  bearings  were  difficult  of  diagnosis.  The 
last  series  of  cases  under  my  care  have  thrown  considerable 
light  upon  the  whole  nature  of  the  disease,  and  I  therefore 
feel  constrained  to  relate  somewhat  minutely  its  clinical 
history.  In  my  earlier  batch  of  cases  the  ophthalmoscope,  to 
my  intense  astonishment  and  regret,  aided  me  not  at  aH.  This 
I  now  ascribe  to  the  fact  that  the  cases  then  seen  by  me  were 
of  early  date,  the  patients  having  applied  for  medical  aid  so 
soon  as  the  disease  appeared  and  before  structural  change 
(intra-cranial)  had  become  sufficiently  complete  to  affect  the 
retinal  circulation  or  affect  in  any  way  the  nutrition  of  the 
optic  tracts.  Another  and  more  potent  reason  of  failure  to 
detect  pathological  change  was  the  short  time  the  patients 
remained  under  observation ;  expecting,  as  they  did,  imme- 
diate relief  and  not  receiving  it,  determined  them  to  seek  and 
if  possible  obtain  it  elsewhere,  and  so  I  was  deprived  of  the 
opportunity  of  further  clinical  observation. 

In  three  out  of  the  number  of  miners  now  and  lately  under 
my  care,  the  disease  has  been  of  some  standing,  and  there- 
fore I  have  been  able  to  arrive  at  a  more  correct  conclusion 
as  to  its  etiology  and  pathology. 

I  will  relate  the  history  of  one  case  now  under  my  care, 
which  is  more  or  less  typical  of  the  rest. 

March  11,  1880. — W.  W.,  set.  44,  states  that  three  years 
ago  his  visual  co-ordination  was  affected  in  the  following 
manner.  He  was  stooping  with  his  head  bent  towards  the 
right  side,  getting  coal,  when  suddenly  the  light  of  his  lamp 
appeared  to  be  moving  rapidly  to  and  fro.  Much  alarmed, 
he  at  once  assumed  the  erect  posture,  when,  on  again  looking 
at  the  lamp,  the  light  was  stationary.  The  account  of  the 
commencement  of  the  disease  is  the  same  in  each  case  I  have 
yet  met  with.     The  nystagmus  is  sudden,  never  preceded  by 


176  NYSTAGMUS. 

symptoms  of  ill-health,  and  afterwards  is  persistent  when 
the  miner  is  at  work,  but  in  many  cases,  indeed  in  most, 
the  patient  has  power  when  in  the  erect  posture  to  regu- 
late and  control  the  muscular  action  of  the  eyeballs.  On 
questioning,  I  elicited  further  facts,  which  were  that  the  day 
following  the  first  attack  of  nystagmus,  as  he  was  preparing 
for  work,  he  was  attacked  by  a  curious  sensation  which  he  said 
arose  at  the  pit  of  his  stomach  and  passed  upward  through 
his  chest  and  neck  towards  his  head  (epileptic  aura).  He 
then  lost  consciousness  for  a  few  seconds,  and  when  reason 
returned,  he  was  surprised  to  find  he  had  unlaced  one  of  his 
boots  which  he  had  immediately  before  fastened  preparatory 
to  leaving  home  for  the  pit.  Since  this  attack  the  fits  have 
recurred  at  intervals  with  nearly  always  the  same  result,  viz. 
the  removal  of  some  article  of  dress,  either  his  coat,  waistcoat, 
or  necktie.  The  nystagmus  is  constant  when  at  work,  but  in 
this  case  the  movements  of  the  globes  (horizontal)  are  performed 
but  a  few  times  in  each  minute,  and  consequently  he  can 
follow  his  occupation  with  moderate  success.  This  is  the  only 
case  I  have  met  with  where  the  patient  can  continue  his  em- 
ployment after  once  the  nystagmus  has  become  persistent.  In 
this  case,  as  in  one  other,  if  the  patient  is  cognisant  of  the 
approaching  fit  he  can,  by  quickly  swallowing  his  saliva, 
prevent  it,  and  he  can  also  ward  it  off  by  taking  a  deep  in- 
spiration. In  the  history  of  this  case,  as  in  that  of  each  one  I 
have  hitherto  gone  into,  there  is  not  a  single  factor  which  we 
so  frequently  meet  with  in  cases  of  a  somewhat  similar  kind,  as 
a  cause,  such  as  syphilis,  tumour  of  brain,  meningitis,  tubercle, 
cerebral  lesion  from  injury,  typhoid  fever,  &c.  The  history  in 
one  and  all  is  remarkable  for  the  absence  of  inherited  troubles, 
and  the  sufferers  have  as  a  rule  been  strong  and  vigorous  prior 
to  the  attack. 

I  have  during  the  past  six  months  seen  six  well-marked 
cases  of  miners'  nystagmus  of  long  standing,  and  in  each 
patient  the  instability  of  the  muscular  apparatus  is  associated 
with  a  low  form  of  epilepsy  (petit  mal).  In  the  less-marked 
case  the  nervous  discharges  are  so  slight  that  without  careful 
study  they  might  be  overlooked. 

These   seizures,  however  slight,  do  undoubtedly  form  one 


NYSTAGMUS.  177 

group  of  minor  epilepsy  which  is  very  frequently  clinically 
neglected  and  very  frequently  misunderstood,  the  treatment 
being  directed  to  the  digestive  tract  solely ;  the  supposition 
being  that  the  brain  is  simply  at  fault,  because  it  is  supplied 
with  blood  of  a  kind  insufficient  for  its  proper  (healthy) 
nutrition.  This  is  not  so;  the  two  diseases  are  totally  dis- 
similar. The  brain  of  the  confirmed  dyspeptic  is  never 
benefited  by  the  exhibition  of  a  drug  likely  to  increase  the 
stability  of  the  nervous  centres,  such  as  bromide  of  potassium 
or  Indian  hemp ;  but,  on  the  other  hand,  is  much  benefited 
by  drugs  which  put  the  general  digestive  tract  into  good 
working  order. 

The  real  cause  of  the  disease  is  difficult  of  explanation. 
The  men  aver  it  is  due  to  the  fact  that  they  are  frequently 
working  up  to  their  waists  in  water  for  long  periods,  and  that 
the  difference  in  the  workings  has  a  material  effect  upon 
their  constitutions. 

Some  pits  are  notorious  for  the  amount  of  water  they 
contain,  and  also  for  the  number  of  men  who  are  habitually 
ailing.  Other  pits  are  characterised  as  the  healthy  ones,  from 
the  fact  that  they  are  practically  free  from  damp,  and  the  men 
working  in  them  are  but  seldom  ill.  I  have  but  little  doubt 
that  this  statement  is  truthful,  and  as  wet  and  cold  are  the 
immediate  cause  of  so  many  serious  diseases  of  the  spinal  cord, 
we  may,  I  think,  say  that  the  frequent  immersion  of  the  lower 
half  of  the  body  in  water  is  the  primary  cause  of  the  disease. 

One  fact  we  must  not  lose  sight  of,  which  is  that  in  miners' 
nystagmus  the  oscillation  of  the  eyeballs  only  occurs  when  the 
miner  is  at  work  and  when  the  head  and  neck  are  much 
bent.  This  fact  leads  us  to  the  belief  that  the  particular  area 
(medulla)  is,  so  long  as  the  neck  is  thus  strongly  bent,  in 
a  condition  of  venous  engorgement,  consequent  upon  the 
pressure  on  the  large  blood-vessels  of  the  neck;  and  as  the 
pressure  is  constant — that  is,  constant  so  long  as  the  man 
remains  at  work — there  is  a  continuous  cell-discharge  from 
unstable  grey  matter,  rendering  visual  co-ordination  impos- 
sible. The  fact  that  so  soon  as  the  patient  assumes  the  erect 
posture  the  nystagmus  ceases,  renders  it  clear  that  venous 
engorgement  is  the  chief  factor  in  this  curious  phenomena. 

VOL.  in.  N 


178  NYSTAGMUS. 

I  copy  from  my  note-book  the  ophthalmoscopic  appear- 
ances of  the  fundus  in  each  of  the  last  eight  cases  of  miners' 
nystagmus : — 

Case  1.  The  discs  are  red.     Marked  venous  stasis. 

Case  2.  The  disc  of  the  right  eye  is  normal,  but  the  veins 
carry  too  much  blood  ;  the  disc  of  the  left  eye  is  pale,  and  the 
venous  stasis  very  marked. 

Case  3.  Hyperemia  of  discs.     Vessels  rather  too  full. 

Case  4.  Discs  natural.     Veins  very  tortuous  and  distended. 

Case  5.  Discs  anaemic.     Vessels  normal. 

Case  6.  The  appearances  are  normal  in  each  eye. 

Case  7.  Hypersemia  of  discs;  veins  singularly  tortuous  and 
distended. 

Case  8.  Discs  red.  Veins  distended.  '  Arteries,  in  com- 
parison, very  small  in  outline ;  possibly  normal  in  calibre,  but 
they  appear  small  in  close  proximity  to  distended  veins. 

With  but  few  exceptions,  the  ophthalmoscope  disclosed  a 
venous  stasis  which  is  always  more  or  less  persistent.  In  a 
few  cases  opposite  conditions  of  the  disc  are  noticed :  in  some 
eases  we  find  anaemia,  in  others  hypersemia,  and  occasionally 
the  disc  appears  normal. 

Treatment  proves  but  of  little  avail.  I  have  tried  many 
drugs,  and  have  continued  their  use  for  long  periods,  but 
have  never  as  yet  met  with  success.  The  nearest  approach  to 
success  was  in  the  case  of  a  man  who  suffered  from  a  very 
exceptional  form  of  miners'  nystagmus  (the  oscillation  being 
continuous).  The  liq.  strychnia?  had  a  speedy  and  marked 
effect  in  checking  the  undue  movement  of  the  globes  whilst 
he  was  away  from  work.  On  resuming  work,  as  soon  as  he 
bent  his  head  and  neck  the  nystagmus  returned,  and  he  was 
compelled  to  again  leave  his  employment. 


ON   MUSCULAR   SPASMS    KNOWN    AS    "TENDON- 
REFLEX." 

BY   AUGUSTUS   WALLER,   M.B. 

Much  attention  has  of  late  been  conferred  on  a  certain  class 
of  spasm  symptoms,  viz.  tendon-reflex  phenomena  and  cloni. 
Their  clinical  import  is  an  independent  fact,  their  physio- 
logical interpretation  has  hardly  yet  come  to  rest  in  a 
satisfactory  generalisation.  First  demonstrated  for  the 
extensor  cruris  by  percussion  of  the  ligamentum  patellae, 
the  demonstration  has  been  extended  to  most  of  the  pro- 
minently acting  muscles  of  the  body. 

To  commence  with  the  best-known  instances,  let  us  consider 
the  "  knee  phenomenon  "  and  the  "  ankle-clonus."  These  are 
spasms  elicited — the  former  by  percussion  of  the  ligamentum 
patellae — the  latter  by  sudden  passive  flexion  of  the  foot. 
The  former  is  seen  as  a  single,  the  latter  as  a  multiple  spasm, 
and  they  are  commonly  found  associated  in  threatened,  inci- 
pient, or  progressing  contracture.  The  first  question,  therefore, 
that  suggests  itself  is :  wherefore  a  single  rectus-spasm  and  a 
multiple  gastrocnemius-spasm  ? 

Assuming  that  the  effect  on  the  muscle  is  brought  about 
by  a  pull  of  its  ligament,1  the  answer  is  obvious.  At  the 
knee  the  single  blow  is  the  single  stimulus  to  a  muscle  which 

1  Tschiriew  ('Arch.  f.  Psych,  viii.  3)  has  shown  that,  with  an  uninjured 
tendon,  percussion  is  the  only  stimulus  that  can  excite  the  spasm ;  that  this 
stimulus  remains  effective  after  ligature  and  crushing  of  the  tendon,  and  after 
division  of  all  nerves  to  the  joint;  that  subsequently  a  sharp  pull  of  the  cut 
tendon  still  excites  the  spasm.  Dr.  Gowers'  observations  point  to  the  same  conclu- 
sion. Further,  electrical  stimulation  of  the  ligamentum  patellaB  does  not  provoke 
any  muscular  reaction  ;  and  in  investigating  cases  where  there  is  no  reaction  to 
tendon  percussion,  the  difference  between  a  blow  on  the  patella  or  on  its  ligament 
can  be  felt  by  the  hand  placed  on  the  rectus.  In  the  latter  case,  vibration  of 
percussion  is  far  more  distinctly  perceived. 

N   2 


180  ON  MUSCULAR  SPASMS   KNOWN  AS 

contracts  and  then  remains  quiescent ;  at  the  ankle  the  first 
contraction  excited  by  the  tension  of  passive  flexion  restores 
the  mechanical  readiness  to  a  second  tension  stimulus  by 
passive  flexion — the  reactions  of  the  muscle  break  a  continued 
flexion  into  successive  jerks,  each  jerk  causing  a  contraction, 
each  contraction  making  ready  for  a  jerk.  A  clonus  or  series 
of  spasms  thus  obtains  which  is  not  to  be  classed  as  a  rhythm 
by  continuous  influence. 

Just  as  the  exaggerated  phenomena  are  commonly  asso- 
ciated in  disease,  so  are  their  normals  commonly  associated  in 
health.  The  kick  provoked  by  a  blow  just  above  or  below 
the  knee  and  the  dancing  of  the  leg  are  tricks  of  boyhood, 
and  every  one  knows  how  suddenly  a  man  can  be  pulled 
down  by  a  blow  across  his  hamstrings.  We  see  in  them  the 
same  difference  of  "facon  d'agir"  as  in  their  clinical  con- 
geners— in  the  one  case  a  single  tensile  jerk  to  the  tendons 
of  thigh-muscles,  in  the  other  a  tensile  jerk  to  the  tendon  of 
the  calf-muscles,  repeated  at  each  fall  of  the  limb. 

The  identity  of  the  mechanism  is  further  established,  inas- 
much as:  1st.  A  single  tap  on  the  tendo  Achillis  of  the  free 
foot  causes  a  single  extension  of  the  foot.  2nd.  Percussion  to 
the  rectus  of  a  fixed  leg,  evokes  both  in  normal  and  abnormal 
cases,  not  always  a  single  spasm  only,  but  sometimes  a  short 
series  of  two,  three  or  more  spasms.1  3rd.  In  cases  of  abnormal 
exaggeration,  a  knee-clonus  may  sometimes  be  demonstrated, 
of  the  same  spasm-frequency  as  the  ankle-clonus.  In  some 
normal  cases  the  clonic  tremor  with  which  we  are  familiar  in 
muscles  crossing  the  ankle-joint,  may  be  imperfectly  imitated 
in  muscles  crossing  the  knee-joint,  by  placing  the  leg  so  that 
the  relation  between  tendon-extension  and  weight  to  be  lifted 
will  allow  the  falling  weight  to  excite  the  contraction  that 
raises  it  again. 

Muscular  contraction,  provoked  by  muscular  extension,  is 

1  This  may  be  explained  as  follows :  The  elastic  extensibility  of  muscle  is 
greatest  during  contraction.  If  it  contract  while  both  its  insertions  remain 
fixed,  its  actual  length  is  unaltered,  while  physiologically  it  is  extended  by  the 
resistance  to  its  own  contraction.  Thus  it  is,  that  percussion  of  the  ligament  of 
the  fixed  rectus  causes  (1)  contraction  in  response  to  tensile  jerk ;  (2)  contraction 
in  response  to  the  momentary  passive  hyper-extension  at  cessation  of  con- 
traction. 


"  TENDON-REFLEX."  181 

the  element  common  to  all  these  phenomena;  any  blow  on 
tendon,  or  muscle,  or  near  muscle,  that  excites  the  muscular 
fibre,  does  so  by  extensile  vibration. 

Knee-clonus,  as  a  clinical  symptom,  is  frequently  to  be 
found  in  cases  where  the  ankle-clonus  is  pronounced.  It  may 
be  produced,  sometimes  by  a  flexing  jerk  of  the  extended  limb, 
sometimes  by  percussion  of  the  ligament,  or  muscle,  or  patella, 
and  it  sometimes  supervenes  on  an  attempt  to  extend 
the  leg,  or  in  continuation  of  a  single  excited  spasm, 
when  its  spasm-frequency  is,  of  course,  diminished  by  the 
weight  of  the  oscillating  limb.  It  is  necessary  that  there 
should  be  a  certain  balance  between  muscular  contraction  and 
resistance  to  contraction,  in  order  that  the  movement  initiated 
by  any  tensile  jerk  shall  be  repeated  by  sudden  restoration  of 
extending  resistance.  The  foot  lends  itself  to  the  setting  of 
this  balance  far  more  aptly  than  does  the  leg,  and  it  is  more 
difficult,  on  a  patient,  to  demonstrate  knee-clonus  than  ankle- 
clonus,  or  on  oneself,  with  unenhanced  irritability,  to  set  going 
a  knee-clonus  than  to  arrange  the  foot  to  dance.  Perhaps  the 
easiest  method  to  get  a  knee-clonus  is  to  tap  the  patellar 
tendon  of  the  leg  fixed  at  a  certain  angle  of  flexion ;  a  short 
series  of  spasms  will  appear  in  the  rectus,  presumably  when 
the  conditions  allow  of  reverberation  between  contraction, 
and  momentary  extension  on  cessation  of  contraction.  By 
extending  the  leg  for  an  instant,  and  allowing  it  to  drop 
slowly,  it  may  be  noticed  that  as  it  passes  through  a  certain 
angle  of  flexion,  breaks  in  the  uniform  movement  occur; 
just  as  in  the  slight  nystagmus  of  debility,  lateral  jerks  are 
seen  at  a  certain  ocular  angle,  which  disappear  with  further 
effort,  and  reappear  on  its  gradual  relaxation.  Such  tremor, 
whether  it  be  in  leg,  or  eye,  or  other  part,  is  a  rudimentary 
instance  of  the  more  striking  and  easily  excited  clonus, 
or  nystagmus,  or  epileptiform  spasm  of  morbid  irritability. 
It  is  possible  for  a  brief  period  voluntarily  to  maintain 
the  leg  at  that  angle  where  extension  by  weight  and  weight- 
sustaining  contraction  shall  be  so  related  as  to  reverberate. 
But  the  conditions  to  a  continuance  of  such  motion  are  not 
favourable ;  the  limb  tends  to  fall  out  of  the  correspon- 
dence between  muscular  extension  and  muscular  contrac- 
tion, which  is  the  condition  of  the  rhythm,  i.e.  there  is  too 


182 


ON   MUSCULAR   SPASMS   KNOWN   AS 


much  weight,  too  little  contraction ;  or  it  is  raised  out  of  the 
correspondence  by  an  excess  of  voluntary  contraction,  i.e.  there 
is  too  little  weight,  too  much  contraction.  When,  however, 
the  muscle  has  become  fatigued  by  more  prolonged  extension, 
this  excess  of  contraction  over  weight  becomes  removed,  and 
the  clonic  tremor  may  be  seen  to  supervene  in  the  completely 
extended  leg. 

The  following  table  contains  the  condensed  notes  of  cases 
hearing  on  points  in  question,  with  time  measurements  of 
some  of  the  phenomena. 


No. 


II. 
III. 

IV. 
V. 


VI. 

VII. 

VIII. 

IX. 
X. 

XI. 


Case. 


Bight  Hemiplegia    . 


Cerebral    Disease. — Double 
optic  neuritis.     Tumor? 


Syphilitic  Paraplegia  . 


Paraplegia    ..... 

Anterior  Poliomyelitis. — Ex- 
posure during  Zulu  war ; 
no  contraction  in  response 
to  percussion  at  any  part 
other  than  left  wrist ;  re- 
actions of  degeneration. 


Normal 


Bight  Hemiplegia 
Double  Sciatica  . 
Locomotor  Ataxy 
(?)  • 


Spinal  Syphiloma.  — On  left 
side,  no  reaction  to  pa- 
tellar-tap,  no  knee-clonus, 
ankle-clonus,  reactions  to 
front- tap  and  Achillis-tap 
excessive.  On  right  side, 
reaction  to  patellar-tap 
excessive,  knee-clonus, 
slight  ankle-clonus. 


Phenomenon. 


Patellar  tap  to  rectus-con- 
traction 


Patellar-tap  to   rectus-con 

traction 
Front- tap  to  gastrocnemius--! 

contraction     .      .      .      ./ 

Pakllar-tap  to  rectus-con- 
traction 


Ditto  .... 
to    wrist-exten- 


Wrist-tap 
sion 


Patellar-tap  to  rectus  con- 
traction    .... 


Ditto .      .      , 
Ditto .     .     . 

Ditto .     .      . 

Ditto  .     .     . 
Front-tap  to  gastrocnemius 
contraction 

Patellar-tap  to  rectus  con 
traction     .... 

Front-tap  to  gastrocnemius 
contraction      . 

Achillis-tap  to    gastrocne 
mius-contraction  .     . 

Knee-clonus,  R.  per  sec. 

Ankle-clonus,  L,  per  sec 


',.  -04 
,.   -045 

•04 
•045 

•035- -04 


R.  -05 
L.    05 

•0525 


•05 

•05 
0475 

•05 
•05 


R. 
L. 

•055 
•055 

•0425 

•04 

R. 

•05 

L. 

05 

L. 

•05 

10 

10 

"  TENDON-REFLEX." 


183 


No. 


XII. 


XIII. 


XIV. 


XV. 


XVI. 


Disseminated  Sclerosis.  — 
Right  hemiplegia  13 
years  ago.  On  right  side 
exaggerated  patellar  re- 
action, ankle  clonus,  knee- 
clonus  . 

Left  Hemiplegia.  —  Right 
rectus  reaction  excessive. 
This  was  the  only  excep- 
tion to  the  rule,  viz.  in- 
creased excitability  on  the 
diseased  side.  There  may 
have  been  an  error  of 
measurement,  or  in  my 
notes ;  or  the  reaction 
may  have  been  becoming 
abolished.  The  case  was 
lost  sight  of. 


Normal 


Progressive  Muscula  rA  trophy 


Paraplegia.  —  So  -  called 
spinal  epilepsy.  Any  sort 
of  impression  is  liable  to 
induce  violent  spasmodic 
agitation.  If  patient  ex- 
tend his  leg,  it  instantly 
enters  into  violeut  clonus, 
followed  by  clonus  of  the 
opposite  leg,  of  the  ab- 
dominal muscles,  and  of 
the  upper  extremities. 
The  violence  of  the  move- 
ment is  such  as  to  shake 
the  bed  and  even  the 
room.  Cold  or  anger  are 
particularly  liable  to  ex- 
cite the  agitation.  By 
firmly  grasping  the  rec- 
tus, the  clonus  of  that 
muscle  may  be  arrested. 
The  patient's  friends  have 
been  accustomed  to  sit 
upon  him,  in  order  to 
arrest  the  general  convul- 
sion. 


Phenomenon. 


Time. 


Patellar-tap 
traction 


to  rectus-cou 


•}{£ 


•45 
•6 


Patellar-tap  to  rectus-con 
traction 

Achillis-tap  to  gastrocue 
mius  contraction  . 

Galvanic  stimulus  to  rectus 

Galvanic  stimulus  to  gas- 
trocnemius     . 

Wrist-lap  to  biceps  con- 
traction      

Ankle-clonus,  per  sec.  . 
Knee-clonus,  per  sec.    .     . 


.1 


•036 

•04 

•033 

•033 

•05 


184 


ON  MUSCULAR  SPASMS  KNOWN  AS 


No. 

Case. 

Phenomenon. 

Time. 

XVII. 

Left    Hemiplegia.  —  It    is 

Wrist-tap     to    biceps-cou-1 

045 

noteworthy  that  a  tap  on 

radius   provokes    flexion 

Patellar- tap   to  rectus-con-1 

•05 

of   the   forearm;    a  tap 

on    ulna,    extension    of 

the   forearm ;    a  tap  on 

knuckles,  flexion  of  the 

fingers 

XVIII. 

Syphilitic  Paraplegia. — No 
response  of  rectus  to  pa- 
tellar-tap  on  either  side ; 
on    right    side,    foot   is 
everted  in  response  to  a 
tap  on  the  ligament,  or 

• 

on  the  patella,  or  on  the 

• 

tibia ;  at  the  same  time 

the  hamstrings   are  felt 

to  tighten. 

XIX. 

Bight      Hemiplegia      and 
Aphasia. — Late   contrac- 
ture in  active  state.    A 
tap  on  any  bony  point  of 
right  arm  or  on  clavicle 
provokes  violent  flexion 
and  extension,  chiefly  of 
the  arm,  frequently  pass- 

ing   iuto    a   rapid    true 

clonus  of  the  whole  ex- 

tremity, lasting  about  30 

■"' 

seconds. 

XX. 

Left  Syphilitic  Hemiplegia. 
— All    reactions  are  in- 

creased on  left  side.  Ex- 
cessive reactions  of    se- 
veral muscles  of  upper 
extremity  to  tap  on  wrist. 
It  is  noticeable,  however, 
that  with  tap  on  radius, 
or  radial  side,  a  flexion 
of   the  arm  is   evoked ; 
with  a  tap  on  the  ulna, 
or  ulnar  side,  an  exten- 
sion;   tap    on    knuckles 
excites  flexion  of  fingers. 

XXI. 

Traumatic  Paraplegia  .     . 

("Ankle-clonus,  per  sec.  . 
(Knee-clonus,  per  sec.    . 

8  to  9 
10 

XXII. 

Traumatic       Paraplegia    \ 

/Ankle-clonus,  per  sec.  . 

10 

9      . 

"  TENDON-REFLEX."  185 

It  obtained  throughout  the  above  cases  that  a  greater 
irritability  of  muscle  to  extensile  vibration  is  associated  with 
lesions  that  isolate  spinal  segments  from  superior  influences ; 
despite  of  the  usual  association  with  contracture  it  does  not 
necessarily  follow  that  each  reaction  is  from  the  emancipated 
centre,  but  only  that  some  influence  from  the  centre  (viz.  the 
reflex  tonicity  maintained  by  the  spinal  cord)  normally 
furnishes  to  peripheral  elements,  muscular  or  intra-muscular, 
a  condition  of  the  reaction.  Abnormally  under  excess  or 
defect  of  such  influence  the  muscular  reaction  may  be  en- 
hanced or  fail. 

To  resume  the  identification  of  the  phenomena  at  the  knee 
and  ankle-joints,  let  us  consider  the  round  numbers  of  their 
time  estimates.     They  are 

Achillis-tap  to  gastrocnemius  spasm  .  03"  to  *  04" 

Patellar-tap  to  rectus  spasm *03"  to  -04" 

Ankle-clonus 8  to  10  per  sec. 

Knee-clonus 8  to  10  per  sec. 

These  numbers  plead  in  favour  of  the  argument  that  the 
mechanism  of  analogous  spasms  at  the  two  joints  is  identical. 
We  have  seen  cause  to  attribute  throughout  the  same  stimulus 
to  both  kinds  as  types  of  a  class,  therefore  the  mechanism  of 
all  the  above  spasms  is  probably  identical. 

With  regard  to  the  question  common  to  them  all,  namely : 
Is  the  mechanism  wholly  peripheral  or  reflected  from  spinal 
centres  ?  (1.)  Tschiriew  finds  for  the  quadriceps  of  rabbits, 
that  the  reaction  is  abolished  after  section  of  anterior  roots,  or 
of  posterior  roots,  or  of  that  limited  portion  of  the  cord  whence 
the  crural  nerve  proceeds,  even  if  at  the  time  of  tendon-per- 
cussion, muscular  tension  be  maintained  by  moderate  faradisa- 
tion of  the  peripheral  nerve  stump.  (2.)  The  clinical  records  of 
neurologists  (Westphal,  Erb,  Buzzard,  Grainger  Stewart, 
Charcot,  Gowers,  Bramwell,  &c.)  prove  that  the  abolition  of 
the  reaction  corresponds  with  incapacitations  of  spinal  matter 
(e.g.  ataxy,  infantile  paralysis),  that  its  exaltation  is  associated 
with  interruptions  above  grey  matter,  and  is  especially  a 
token  of  irritability,  in  a  centre  undergoing  the  irritation  of 
degeneration  (e.g.  paraplegia,  lateral  sclerosis).  (3.)  As  the 
effect  of  strychnia,  by  which  the  irritability  of  spinal  centres 


186  ON   MUSCULAR   SPASMS   KNOWN   AS 

is  enhanced,  muscular  reactions  increase  in  vigour.  (4.)  The 
latent  interval  between  stimulus  and  contraction  is  pre- 
sumably greater  than  that  of  a  muscular  latency.  (5.)  Con- 
tractions identical  with  those  by  percussion  of  tendons,  may  be 
provoked  by  percussion  of  remote  parts,  e.g.  bony  joints,  and 
in  some  cases  crossed  contractions  are  elicited. 

By  data  (1)  (2)  and  (3),  no  more  is  proved  than  that  a  certain 
influence  from  spinal  centres  is  necessary  to  the  reaction  of 
muscles  by  the  percussion  of  their  tendons ;  (4)  is  of  no 
value — if  a  period  of  *03"  (vide  note,  page  187)  is  above  the 
presumable  value  of  direct  muscular  latency,  it  is  also  (as 
Dr.  Gowers  has  remarked)  below  that  of  a  reflex  event. 
Helmholtz's  original  experiments  gave  for  the  nerve  trans- 
mission-rapidity 30  to  90  m.  per  sec.  according  to  tempera- 
ture. Bloch  has  stated  that  the  rate  might  reach  over 
150  m.  per  sec.  My  own  measurements  assign  to  it  under 
ordinary    conditions    a  value    between   30  and   50  m.   (vide 


Fig.  I. — Nekvk  Transmission-Rapidity. 

Fig.  I.).     Therefore,  roughly  speaking,  to   take   rectus  and 
gastrocnemius   respectively    \  and   1  m.  distant    from    their 

Fig.  I. — Electric  latency  of  a  thumb-index  pinch,  recorded  on  the  revolv- 
ing cylinder  by  a  lever-bearing  tympanum,  with  which  was  connected  an  ex- 
plorer between  thumb  and  index  as  "pince  myographique."  Quick  rate  of 
cylinder  -  3  mm.  =  ^  sec.  —  tuning-fork  tracing  100  vv.  per  sec. 

s  -  8'.  Physical  latency  of  media. 
s  -  c.  Latency  of  stimulus  to  median  at  bend  of  elbow. 
8'  -  c'.  Latency  of  stimulus  to  brachial  nerves  above  clavicle. 
o  —  c'.  Difference,  expressing  time  occupied  by  nerve-impulse   between 
these  two  points. 

N.B.— 8  to  «'  is  the  physical  latency  of  the  transmitting  media  ascertained  by 


"  TENDON-REFLEX."  187 

spinal  centres,  the  nerve-delays  should  be  about  -02"  to  '03" 
and  "04"  to  "06",  to  which  have  yet  to  be  added  the  central 
and  muscular  delays    which    make    up    the   total   reflex   in- 


Fig.  II. — Kxee-Clonts. 


terval.       The    gastrocnemius    reflex    latency    ought     to    be 
sensibly  greater  (about  *02"  to  *03")  than  the  rectus  latency, 


Fig.  III. — Ankle-Clonus. 

whereas  I  have  found  it  to  be  about  the  same  (-03"  to 
•04".  Vide  Figs.  IV.  and  V.).  And  finally  I  find  that  the 
direct  latency  of  the   gastrocnemius  and  rectus  to  galvanic 

independent  measurement.  Stimulation  made  by  contact  of  metal-point  with 
knife-edge  on  revolving  cylinder,  whereby  current  is  closed  and  opened.  Instant 
of  contact  8  recorded,  by  a  contraction  while  cylinder  is  stationary.  Intervals 
between  instant  of  contact  and  contraction  s  —  c,  s  —  c',  shown  with  cylinder  at 
full  speed.  Taking  the  intervening  length  of  nerve  at  30  to  35  cm.,  the  interval 
(in  this  tracing  slightly  less  than  T^")  denotes  a  nerve-transmission  rapidity 
between  40  and  50  metres  per  sec.  In  the  tracing  figured,  three  successive  con- 
tractions of  each  stimulus  were  allowed  to  coincide,  as  a  testimony  of  mechanical 
accuracy.  Tracings,  from  which  estimates  were  actually  taken,  were  made  fine 
enough  to  allow  of  microscopic  measurement. 

Fig.  II. — Knee-clonus  (No.  xviii.) ;  Fig.  III.,  ankle-clonus  (No.  xviii.).  (Medium 
rate  of  cylinder,  5  cm.  =  1  sec.) 

Note. — Tschiriew  estimated  the  percussion-contraction  interval  at  ■  033".  Dr. 
Gowers  estimated  it  at  "10" ;  for  the  "front-tap  "  he  found  it  to  be  0i"  to* 05  "; 
for  the  ankle-clonus  he  found  a  spasm  frequency  of  6  to  8  per  sec,  for  a  knee- 
clonus  of  2-5  per  sec.  From  this  he  is  led  to  the  belief  that  at  the  knee  the  phe- 
nomenon is  reflex  (there  being  also  a  slight  indication  of  a  direct  contraction),  while 
at  the  ankle  it  is  direct.  Measurements  that  I  made  to  control  the  discrepancy  led 
me  to  assign  -04"  as  the  mean  latency  of  the  knee-phenomenon,  while  for  the  knee- 
clonus  I  found  a  spasm-frequency  the  same  as  for  the  ankle-clonus  (viz.  8  to  10 
per  sec.)  (vide  Figs.  II.  and  III.).  I  therefore  concluded  that  Tschiriew's  estimate 
is  the  more  accurate  one.  There  may  have  been  a  trifling  excess  in  some  of  my 
first  measurements  (viz.  "05"),  where  percussion  on  a  tube  across  the  ligament 
made  the  signal,  due  to  a  minute  delay  suffered  by  the  percussion  vibration  along 


188  ON   MUSCULAR   SPASMS   KNOWN   AS 

stimuli  applied  to  their  motor  point  is  longer  than  has  been 
assumed,  viz.  about  "02"  {vide  Fig.  VI.).  (5.)  When  percussion 
provokes  contraction  it   is   by  transmission  of  vibrations   to 


Fig.  IV. — Tendon-Percussion  Latency  of  Rectus. 

irritable  muscles,  their  irritability  may  be  so  diminished  that 
vibration  via  tendon  is  insufficient,  and  percussion  directly 
to   their   substance   is   necessary   to   excite   contraction    (e.g. 


Fig.  V. — Tendon-Percussion  Latency  of  Gastrocnemius. 

ataxy).  On  the  other  hand  their  irritability  may  be  so  in- 
creased that  the  vibration  by  percussion  of  the  bone  into  which 

tendon  to  muscle — a  medium  of  imperfect  rigidity — or  to  a  trifling  advantage  in 
time  for  the  manifestation  by  the  lever  of  a  sharp  percussion  impulse  over  that  of 
the  more  massive  contraction  impulse.  M.  Brissaud's  recent  measurements,  with 
which  I  was  not  acquainted  at  the  time,  are  nearly  identical  with  mine,  viz. 
•035"  to  -05". 

Fig.  IV. — Percussion  latency  of  rectus  (normal   subject).     (In  this  tracing 
12  mm.  of  the  abscissa  denote  the  latency,  viz.  -04".) 

P  denotes  percussion  of  lig.  pat. 
c  denotes  contraction  of  quadriceps. 
Fig.  V. — Percussion  latency  of  gastrocnemius  (normal  subject). 
P  denotes  percussion  of  tendo  Achillis. 
c  denotes  contraction  of  calf. 
Recorded    by   a  lever-bearing   tympanum,   in   connection   with  an   explorer 
lixed  on  the  muscle.     A  tube,  branching  off  the  tympanum  tube  and  crossing 
the  tendon,  was  first  employed  to  record  percussion.     But  the  jar  communi- 


"  TENDON-REFLEX."  189 

they  are  inserted,  or  of  still  more  remote  parts,  is  competent 
to  excite  their  contraction.  This  was  well  exemplified  in 
Cases  XVII.  and  XX.,  where  by  percussion  of  radius  the  fore- 
arm received  a  flexing  spasm,  while  that  of  the  ulna  provoked 
an  extending  spasm.  Naturally,  along  rigid  bones  vibrations 
most  readily  travel.     I  have   frequently   observed   the   same 


Fig.  VI. — Electric  Latency  op  Rectus. 

to  occur  in  weakly  subjects  (e.g.  phthisis).  With  regard  to 
"  crossed  reflex "  though  I  have  often  seen  clonus  invade 
the  opposite  extremity,  I  have  not  witnessed  any  case 
where  a  simple  spasm  of  rectus  was  undoubtedly  crossed ; 
at  the  most  there  has  been  adduction  of  the  limb  opposite 
to  the  one  percussed.  In  such  cases  the  excessive  move- 
ment affects  the  trunk,  and  gives  rise  to  an  appearance 
of  contraction  in  the  opposite  limb.  Extent  of  agitation 
appears  to  be  as  naturally  referred  to  extent  of  vibration  in 
irritable  muscles  and  vigorous  contraction,  as  to  spinal 
diffusion.  (6.)  The  percussion-contraction  interval  is  the 
same,  viz.  about  *035",  whether  the  substance  or  the  tendon 
of  the  muscle  be  struck. 

cated  to  the  explorer  by  the  percussion  is  sufficient  (as  in  the  above  two 
tracings)  to  record  its  instant.  It  is  also  more  satisfactory,  since  it  eliminates 
certain  sources  of  fallacy,  e.  g.  time  of  vibration-transmission  along  tendon  and 
muscle. 

Fig.  VI.— Electric  latency  of  rectus  (normal  subject;)  in  this  tracing  the 
latency  is  ■  02"  (quick  rate  -  3  mm.  =  ^  sec). 

Stimulation  made  and  marked  as  in  Fig.  I.  Interval  between  instants  of 
contact  and  contraction  s  —  c  shown  with  cylinder  at  full  speed.  Fifty  successive 
contractions  coincide  in  this  tracing. 

8  —  s'  =  physical  latency  of  media. 
a'  —  c  =  neuro-muscular  latency. 


190  ON  MUSCULAR   SPASMS   KNOWN   AS 

The  ordinary  provocatives  of  neuro-rnuscular  contraction 
may  be  ranked  as  follows,  in  order  of  efficacy : 

|1.  The  galvanic  or  continuous  current. 
|2»  The  faradic,  or  interrupted  current. 

13.  Direct  percussion  of  muscle. 

J  4.  Percussion  of  the  tendon  of  a  muscle.1 

(5.  Percussion  of  the  bone  into  which  its  tendon  is  inserted. 
J  6.  Percussion  of  still  more  remote  parts. 

If  a  muscle  react  to  any  one  of  these  stimuli  it  will  react  to 
all  preceding  stimuli  on  the  above  list.  If  a  muscle  do  not 
react  to  any  one  of  these  stimuli,  it  will  also  not  react  to  all 
succeeding  stimuli.  The  stimulus  to  which  a  normal  muscle 
reacts  ranges  between  3  and  4.  Its  irritability  may  be  in- 
creased so  that  the  muscle  reacts  to  5,  or  to  5  and  6 ;  or  it 
may  be  diminished  so  that  it  only  reacts  to  2  and  1,  or  to  1, 
or  not  at  all.2 

Exceptionally  it  happens  that  at  certain  stages  of  altering 
irritability,  non-response  to  one  stimulus  is  associated  with 
excessive  response  to  a  preceding  stimulus — e.  g.  in  Bell's 
palsy,  as  is  well  known,  there  is  a  period  when  reaction  is  0 
to  faradaism,  -f-  to  voltaic  interruption  ;  in  ataxy  Dr.  Buzzard 
remarks  that  while  reaction  to  tendon-percussion  is  0,  reaction 

1  According  to  the  usual  view,  direct  percussion  of  muscle  provokes  direct 
contraction — percussion  of  its  tendon,  reflex  contraction.  I  find  the  percussion- 
contraction  interval  of  the  former  to  be  *03"  to  -035";  (i.e.  the  same  as  in  the 
so-called  reflex),  and  cannot  therefore  subscribe  to  the  distinction.  At  the  same 
time  I  fully  recognise  the  value  of  the  sign,  the  importance  of  which  in  the 
diagnosis  of  tabes  Dr.  Buzzard  has  made  clear — viz.  absence  of  "tendon-reflex," 
with  muscular  response  to  a  direct  blow,  or  to  faradaism. 

2  Practical  bearings  of  the  above  propositions  are  not  far  to  seek.  For 
instance,  if  a  tap  on  the  ligament  or  on  the  substance  of  any  muscle  cause  it  to 
contract,  we  know,  ipso  facto,  that  that  muscle  will  respond  to  faradaism,  and 
a.  fortiori,  to  galvanism ;  so  that  a  fillip  to  the  muscle  will  frequently  spare  the 
application  of  a  superfluous  electrical  test.  If  it  happen  to  a  litigation  patient 
that  one  physician  should  swear  to  the  presence  of  tendon-reflex,  or  of  mechanical 
irritability — say  in  the  rectus  muscle;  while  another  should  vouch  for  the 
absence  of  electric  contractility  in  the  same  muscle,  we  know  that  the  two  state- 
ments are  incompatible.  The  question  is  reduced  to  one  of  probability  between 
affirmation  of  positive  observation,  and  affirmation  of  negative.  It  is  less  likely 
that  an  observer  testifying  to  a  contraction  seen  and  felt  should  be  the  victim 
of  delusion,  than  that  a  witness  to  the  absence  of  electric  contractility  should 
have  failed  to  test  or  observe  completely. 


"  TENDON-REFLEX."  191 

to  direct  percussion  frequently  appears  to  be  -|-.     Of  these 
facts  I  do  not  attempt  any  explanation  at  present. 

I  am  led  to  doubt  the  now  generally  accepted  theory  that 
the  reactions  known  as  clonus  and  tendon-reflex  are  sub- 
served by  spinal  nervous  arcs ;  while  I  admit  as  their  highly 
probable  "  sine  qua  non "  the  reflex  tonicity  exerted  by  the 
spinal  cord.  The  fact  remains  constant  that  spinal  conditions, 
by  some  influence,  be  it  mediate  or  immediate,  modify  the 
response  of  muscle  to  extensile  vibration.  The  foregoing 
paper  contains  facts  militating  against  the  theory  in  possession ; 
it  does  not  furnish  data  of  theoretic  construction,  I  have 
therefore  no  right  to  evolve  gratuitous  supposition.  The 
question  has  interests  broader  than  those  involved  in  the  inter- 
pretation of  a  clinical  symptom  ;  its  discussion  is  reserved 
for  a  future  occasion. 


ON  RIGHT  OR  LEFT-SIDED  SPASM  AT  THE  ONSET 
OF  EPILEPTIC  PAROXYSMS,  AND  ON  CRUDE  SEN- 
SATION WARNINGS,  AND  ELABORATE  MENTAL 
STATES. 

BY  J.   HUGHLINGS-JACKSON,  M.D.,  F.B.C.P.,  F.R.S., 

Physician  to  the  London  Hospital,  and  to  the  National  Hospital  for  the  Epileptic 

and  Paralysed. 

In  this  paper  I  speak  of  the  epilepsy  of  nosologists,  sometimes 
called  "genuine"  epilepsy,  or  epilepsy  proper.  In  this 
epilepsy  consciousness  is  either  lost  first  of  all  or  very 
early  in  the  paroxysm.  Loss  of  consciousness,  as  the  first  or 
nearly  the  first  thing  in  a  paroxysm,  is,  I  presume,  a  sign  that 
the  central  discharge  begins  in  some  part  of  the  highest 
cerebral  centres.  In  epileptiform  seizures  consciousness  is 
lost  late,  and  is  not  affected  at  all  when  the  convulsion  is  very 
limited  in  range ;  in  these  seizures  the  discharge  begins  in 
some  part  of  the  lower  cerebral  centres  (in  some  part  of  Hitzig 
and  Ferrier's  region).  I  think  it  is  important  to  note,  not 
only  in  epileptiform  seizures  but  in  epileptic  seizures,  on 
which  side  the  first  spasm  or  other  abnormal  condition  is. 
Hence  we  ought  to  inquire  whether  the  patient  be  right  or 
left-handed.  In  many  cases  of  epilepsy  proper  the  spasm  is 
for  the  most  part  bilateral,  but  rarely  is  it  quite  equal  and  con- 
temporaneous on  the  two  sides  at  its  onset.  In  many  cases  the 
head  or  eyes  or  both  turn  to  one  side  at  the  onset.  We  ought 
to  try  to  get  to  know  to  which  side  the  first  turning  is.  Un- 
fortunately the  accounts  given  by  the  patient  or  his  friends  are 
often  little  trustworthy.  Besides,  sometimes  the  head  first 
turns  to  one  side  and  then  to  the  other ;  I  mean  that  some- 
times turning  to  each  side  occurs  before  spasm  spreads  to  the 
limbs  or  trunk,  or,  at  any  rate,  before  it  involves  either  of  these 


ON   RIGHT   OR   LEFT-SIDED   SPASM.  193 

regions  in  any  marked  degree.  I  had  recently  under  care  a 
case  of  convulsion  in  which,  in  one  seizure,  the  head  turned  to 
one  side  at  the  onset,  and  in  the  very  next  seizure  to  the  other. 
If  we  find,  however,  that  the  first  spasm  is  always  on  the  same 
side  in  every  seizure,  we  may  reasonably  infer  that  the  "  dis- 
charging lesion "  is  of  some  part  of  the  opposite  cerebral 
hemisphere.  In  some  cases  there  is  no  turning  to  one  side ; 
the  eyes  may  go  up  and  the  head  back.  I  suppose  this  is 
owing  to  great  rapidity  of  the  discharge. 

I  think  the  time  has  come  for  recognising  that  many 
different  epilepsies  are  grouped  under  the  one  term  epi- 
lepsy ;  we  have  come  to  recognise  that  at  least  several 
different  epileptiform  seizures  are  grouped  under  the  term 
epileptiform.  The  paroxysm  of  epilepsy  which  begins  by 
vertigo  is  a  different  epilepsy  from  that  beginning  by  a  sensa- 
tion referred  to  or  near  to  the  epigastrium  (solar  plexus  ?).  The 
seats  of  the  "  discharging  lesion "  must  differ  when  there  are 
these  two  different  paroxysms.  There  are,  at  any  rate,  as  many 
different  epilepsies  as  there  are  different  warnings  ;  the  so-called 
warning  is  simply  the  first  result  from,  or  during,  the  central 
discharge  ;  it  is  the  thing  of  most  localising  value.  Besides,  it 
would  appear  to  be  very  evident  that  the  "  discharging  lesion  " 
may  be  in  either  the  right  or  in  the  left  cerebral  hemisphere.  I 
wish  to  urge,  Firstly ;  that  we  should  study — not  the  epilepsy  of 
nosologists,  but  each  different  epilepsy  as  distinguished  by  its 
particular  warning.  I  fully  believe  that  it  is  a  good  thing  to 
take  epilepsy  to  be  a  sort  of  clinical  entity,  and,  for  an 
example,  to  work  up  the  "  warnings  of  epilepsy."  In  this  way 
we  can  say  that  of  sensation  "  warnings  of  epilepsy,"  coloured 
vision  is  common,  noise  in  the  ear  rare,  and  taste  very  rare. 
Such  are  empirical  generalisations  of  value.  Like  other 
physicians  I  have  long  worked  in  this  way.  But  to  make 
rational  generalisations  we  should  also  work  in  another  way. 
Instead  of  speaking  only  of  different  warnings  "  of  epilepsy," 
I  think  we  should  say,  too,  that  there  are  different  epilepsies 
each  with  its  own  warning,  and  some  with  no  warning. 
Secondly ;  we  should  observe  each  epilepsy  throughout,  from 
the  warning,  if  there  be  one,  through  the  paroxysm,  to  the  after 
condition  of  actions,  when  there  are  any.     To  begin  with,  we. 

vol.  in.  o 


194  ON   RIGHT   OR   LEFT-SIDED   SPASM. 

must  study  groups  of  cases  according  to  the  warnings.  This 
kind  of  study  is  extremely  difficult.  It  is  to  be  understood  that 
some  of  the  statements  I  put  forward  as  results  of  such  study 
are  made  with  great  diffidence  as  to  their  exactness.  He 
who  undertakes  a  task  of  this  kind  is  sure  to  make  mistakes, 
however  careful  he  may  be.  This  short  paper,  I  may  say, 
represents  great  labour. 

I  dare  not  state  it  as  a  fact,  but  my  impression  is  that  when 
an  attack  of  epilepsy  starts  by  vertigo,  in  the  sense  of  there  being 
apparent  movement  of  objects  to  one  side,  the  first  part  of  the 
convulsion  is  usually  right-sided,  and  that  external  objects 
appear  to  be  displaced  to  the  right.  Such  vertigo  would 
signify  discharge  of  some  part  of  the  left  cerebral  hemisphere. 
I  have  put  this  doubtfully,  partly  on  account  of  the  difficulty 
there  is  in  getting  trustworthy  information  from  the  patients 
and  their  friends,  and  partly  because  some  observations  made 
at  my  request  do  not  support  impressions  from  what  I  have 
personally  gathered  from  patients.  It  may  here  be  remarked 
that  the  term  "  vertigo  "  is  often  used  somewhat  loosely.  I  do 
not  take  the  expression  "  giddiness  "  from  a  patient's  mouth  to 
always  mean  true  giddiness.  We  have  to  put  down  not  his 
name  for,  but  the  description  he  gives  of,  the  sensation  he  calls 
giddiness.  Unless  we  take  pains  to  be  accurate  in  our  exami- 
nations as  to  the  question  propounded,  our  observations  will  be 
of  little  value.  The  investigator  who  simply  asks  leading  ques- 
tions on  this  and  some  other  matters  to  be  mentioned  shortly  is 
not  accumulating  "  facts,"  but  is  "  organising  confusion."  He 
will  make  errors  enough  without  adopting  a  clumsy  plan  of  in- 
vestigating which  renders  blundering  certain.  I  would  expressly 
remark  that  by  the  expression  "  epileptic  vertigo,"  a  slight  fit 
of  epilepsy  is  not  meant,  but  vertigo  in  a  slight  fit  of  epilepsy, 
or  at  the  onset  of  a  severe  one— that  the  patient  has  the  sensa- 
tion of  external  things  moving  or  of  himself  turning.  I 
submit  that  it  is  inconvenient  to  use  the  term  "  epileptic 
vertigo  "  for  slight  epileptic  paroxysms  in  which  there  is  no 
vertigo. 

Some  patients  have  a  "  warning  "  of  smell ;  others,  a  sensation 
referred  to,  or  to  the  neighbourhood  of,  the  epigastrium  ;  others 
have,  sometimes  in  addition  to  one  of  the  above-mentioned  crude 


ON   EIGHT   OR   LEFT-SIDED   SPASM.  195 

sensations,  movements  of  mastication,  or  movements  like  those 
of  tasting.  With  these  warnings  the  first  spasm,  if  there 
be  any,  is  usually  on  the  left  side.  I  suppose  the  movements 
mentioned  indicate  discharge  of  centres  for  taste,  although  the 
patient  has  no  sensation  of  taste.  It  is  very  rare  to  find  any 
sensation  of  taste  as  a  "  warning  "  of  any  kind  of  seizure. 

I  must  stay  to  remark  on  the  movements  above-mentioned. 
It  is  submitted  that  they  cannot  result  directly  from  an 
epileptic  discharge.  An  epileptic  (that  is  a  sudden  and  an  ex- 
cessive) discharge  of  the  nervous  arrangements  for  these  move- 
ments would  produce  that  contention  of  movements  which  is 
spasm,  not  movements  properly  so-called.  I  suppose  they  are 
indirect  (reflex)  consequences  of  discharge  of  nervous  arrange- 
ments serving  during  taste.  Mutatis  mutandis  for  rubbing 
the  hands  (discharge  of  tactual  centres  ?),  and  writhing  of  arms 
during  suspended  respiration,  in  other  seizures.  The  hypothesis 
put  forward  is  quite  in  accord  with  one  of  Terrier's  deductions 
from  an  experiment,  is  indeed  a  re-statement  of  it  with  applica- 
tion to  disease.  Ferrier  ('Functions  of  the  Brain,'  p.  189) 
writes  :  "  As  regards  taste,  I  think,  that  the  phenomena  occa- 
sionally observed  in  monkeys  on  irritation  of  the  lower  part  of 
the  middle  temporo-sphenoidal  convolution,  viz.  movements 
of  the  lips,  tongue,  and  cheek-pouches,  may  be  taken  as  reflex 
movements  consequent  on  the  excitation  of  gustatory  sensa- 
tions." In  some  slight  cases  of  epilepsy  the  patient  spits.  I 
suppose  no  one  would  imagine  such  a  highly  compound  move- 
ment to  result  (directly)  from  an  epileptic  discharge.  It  might, 
I  submit,  be  plausibly  put  down  as  an  indirect  consequence  of 
discharge  of  gustatory  central  nervous  arrangements.  So  then 
in  some  slight  fits  of  epilepsy  we  have  not  only  that  "  clotted 
mass "  of  movements  we  call  spasm,  but  also  movements  pro- 
perly so-called.  (I  think  too  that  there  is  in  some  cases,  be- 
sides spasm,  inhibition  of  lower  motor  centres  and  consequent 
paralysis.) 

There  is  another  way  in  which  the  warnings  mentioned  may 
he  considered,  as  they  are  excessive  and  crude  developments  of 
objective  or  of  subjective  sensations.  Unfortunately  the  terms 
"  objective  "  and  *  subjective,"  so  frequently  used  by  medical 
men,  are  used  in  different  senses.      Thus,  sometimes  the  term 

o  2 


196  ON  EIGHT   OK   LEFT-SIDED   SPASM. 

"  subjective  "  is  used  for  psychical  states  in  contrast  to  the  ac- 
companying nervous  states,  Avhich  latter  are  then  called  objective. 
Sometimes  the  term  "  subjective,"  or  the  subject,  is  used  for 
mind,  or  even  without  distinction  between  mind  and  organism, 
in  contrast  to  the  environment,  which  latter  is  then  considered 
objective,  or  the  object.  Sometimes  the  term  "subjective  "  is  used 
for  a  sensation  internally  initiated,  and  the  term  "  objective  " 
for   a   sensation  peripherally  initiated  ;   thus,  a  patient  who 
can  smell  nothing,  and  yet  has  stenches  in  his  nose  (at  the 
onset  of  epileptic  seizures,  for  example),  is  said  to  have  no 
objective  sense  of  smell,  but  to  have  subjective  smell.     Some- 
times the  term  "  subjective  "  is  used  for  the  patient's  abnormal 
states  of  mind,  pain,  for  an  example,  as  when  it  is  said  "  all  his 
symptoms  are  subjective,"  in  contrast  to  the  symptoms  the 
medical  man  can  himself  testify  to,  spasm,  paralysis,  cardiac, 
murmurs,  &c.     These  different  contrasted  applications  of  the 
two  terms  lead  to    great  confusion  in  medical  writings,  and 
particularly  when  the  same  writer  uses  them  sometimes  one 
way   and  sometimes   another.      I   imagine   even    that    some 
philosophical  writings  are  difficult  to  understand,  because  the 
term  "  subjective  "  is  used  sometimes  for  mind  and  sometimes  for 
organism ;  and  the  term  "  objective  "  sometimes  for  nervous  states 
and  sometimes  for  environment  (both  the  organism  and  the 
environment  are  "  outside  "  mind).     Hence,  without  venturing 
to  say  how  the  two  terms  ought  to  be  used,  I  may  properly  say 
how  I  use  them  in  this  article.     I  use  them  both  as  psychical 
terms ;  the  term  "  subjective  "  answers  to  what  is  physically 
the  effect  of  the  environment  on  the  organism ;    the   term 
"  objective  "  to  what  is  physically  the  reacting  of  the  organism 
on  the  environment.     The  reader  will  note  that  it  is  not  said 
that  subjective  stands  for  what  is  on  the  physical  side  the 
organism,  and  objective  for  what  is  environment,  but  that  they 
are  used  for  what  are  on  the  physical  side  the  two  conditions 
of  the  organism  in  its  correspondence  with  the  environment. 
The   correspondence   is   duplex,  and  all  mental   action  is   a 
rhythm  of  subjective  and  objective  states. 

Whether  vertigo  of  the  kind  defined  can  be  shown  to  occur 
most  often  during  discharge  of  the  left  cerebral  hemisphere  or 
not,  it  is,  at  any  rate,  a  crude  development  of  the  most  re- 


ON   EIGHT   OR   LEFT-SIDED   SPASM.  197 

presentative  of  all  objective  sensations.  Ocular  movements 
represent  the  most  special  adjustments  of  the  organism  to — 
of  all  its  reactions  upon — the  environment.  They  are  the  move- 
ments especially  concerned  during  orientation.  The  vertigo  men- 
tioned is  a  crude  sensation  occurring  during  strong  discharge 
of  the  nervous  arrangements  for  these  movements,  and  is  dis- 
orientation, as  coloured  vision  is  blindness.  In  fact,  the  so-called 
warning  (vertigo)  is  itself  consciousness  ceasing  in  a  particular 
way.  What  is  physically  a  losing  of  the  most  special  adjust- 
ments of  the  organism  to  the  environment  (disorientation)  cor- 
responds to  what  is  psychically  (object)  consciousness  ceasing. 

Since  most  people  are  right-handed,  the  left  cerebral 
hemisphere  in  most  people  represents  the  most  objective 
movements,  those  movements  for  most  specially  operating  on 
the  environment.  Moreover,  speech  is  a  process  by  which  are 
symbolised  relations  of  things  in,  or  as  if  in,  the  environment ' 
or  things  considered  objectively ;  nearly  all  evidence  goes  to 
show  that  the  left  cerebral  hemisphere  is  in  most  people  the 
one  concerned  during  speech.  I  make  these  remarks  on  speech 
in  order  to  ask  if  temporary  aphasia  does  not  more  often  occur 
after  those  epileptic  seizures  which  start  by  vertigo  ?  I  am 
not  speaking  of  the  well-marked  and  very  definite  temporary 
aphasia  which  is  found  after  some  right-sided  epileptiform 
seizures.  After  some  epileptic  seizures  there  is  temporary 
"  abnormal  talking,"  and  this  is  sometimes  aphasic. 

Smell  and  taste  are  the  two  of  the  five  special  senses  which, 
even  popularly  speaking,  are  the  most  subjective.  Besides 
the  five  special  senses  there  are  sensations  which  Bain  calls 
"  organic  "  and  Lewes  "  systemic."  The  common  epigastric  sen- 
sation preluding  epileptic  attacks  is,  I  suppose,  a  crude  develop- 
ment of  the  sensation  of  hunger — the  most  representative  of 
systemic  sensations.  If  so,  the  epigastric  warning-sensation  is 
(subject)  consciousness  ceasing.  Hunger  is,  on  the  one  hand, 
a  desire  for  food,  on  the  other  hand  it  represents  the  whole  of 
our  tissues  as  to  their  state  of  nutrition.  At  any  rate  the 
epigastric  sensation  is  a  systemic  and  subjective  sensation. 

1  Of  course  one  does  not  use  the  term  "  environment "  in  its  narrow  dictionary 
meaning.  If  a  man  says  his  leg  is  longer  than  his  arm,  he  is  as  much  making  a 
statement  of  things  objective  as  when  he  says  this  stick  is  longer  than  that. 


198  ON   RIGHT   OR   LEFT-SIDED   SPASM. 

I  do  not  make  the  statements  as  to  the  side  first  in  spasm 
in  relation  with  "subjective"  sensation  warnings,  for  any 
theoretical  reason.  On  the  contrary,  they  are  antagonistic  to 
certain  conclusions  I  have  come  to  from  a  different  kind  of 
evidence.  It  was  a  matter  of  surprise  to  me  to  find  evidence 
of  left-sided  spasm  at  the  onset  of  convulsions  with  these 
"  warnings."  I  used  to  think  the  more  "  subjective  "  of  sen- 
sations were  chiefly  represented  in  the  posterior  part  of  the 
left  cerebral  hemisphere.  The  inference  that  they  occur  most 
often  in  cases  when  the  first  spasm  is  left-sided  is  from  observa- 
tions, and  I  say  again,  observations,  all  of  which  cannot  be 
certainly  trusted,  the  reports  of  patients  and  their  friends  not 
being  always  to  be  relied  on. 

We  have  also  to  note  the  side  first  in  spasm  in  cases  of 
"  warnings  "  by  crude  development  of  the  "  objective  "  sensa- 
tions, sight  and  hearing.  I  think  it  is  usually,  but  certainly 
not  always,  the  left.  Here,  again,  we  must  enquire  about 
right  and  left-handedness.  It  is  certain  that  in  some  epilepti- 
form seizures  with  coloured  vision  the  first  or  sole  spasm 
is  right-sided.  Alexander  Eobertson  ('Brit.  Med.  Journal,' 
April  18,  1874),  narrates  a  case  of  right-sided  (epileptiform) 
convulsion  with  red  vision.  I  have  recorded  the  case  ('  Med. 
Times  and  Gazette,'  June  6,  1863),  of  a  woman  who  had 
right-side  beginning  seizures,  and  at  other  times  "  attacks  "  of 
coloured  vision.  A  left-handed  man  under  my  care  in  the 
Hospital  for  the  Epileptic  and  Paralysed  had  fits  beginning  by 
a  noise  in  the  left  ear.  There  was  in  that  case  tumour  of  the 
right  cerebral  hemisphere  within  the  upper  temporo-sphenoidal 
convolution — Ferrier's  auditory  centre.  Gowers  examined 
the  specimen  for  me,  and  mentions  the  case  in  his  second 
Gulstonian  Lecture. 

All  the  crude  sensations  above  mentioned  are  psychical  states, 
as  indeed  the  term  "  sensation  "  implies.  It  is  a  grievous  error 
to  consider  sensations  as  being  active  states  of  sensory  nerves 
or  sensory  centres ;  doing  so  leads  to  taking  such  warnings  as 
coloured  vision  to  be  of  the  same  order  as  spasm  of  ocular 
muscles,  or  discharge  of  centres  for  them  ;  the  coloured  vision 
is  of  the  same  order  as  vertigo.  When  we  say  that  a  patient  has 
numbness  and  spasm  of  his  hand  at  the  onset  of  an  epileptiform 


ON   RIGHT   OR   LEFT-SIDED   SPASM.  199 

seizure,  we  are  speaking  of  things  different  in  two  ways :  the 
numbness  is  a  crude  sensation,  a  crude  psychical  state  ;  the 
spasm  is  a  physical  symptom :  the  former  occurs  during 
discharge  of  sensory,  the  latter  from  discharge  of  motor 
elements  of  the  centre.  Confusing  sensations  with  states 
of  sensory  nerves  or  centres  leads  also  to  ignoring  that 
sensations  occur  during  energising  of  motor  centres.  Nor 
should  we  use  the  term  "  bodily  sensation,"  unless  it  is  under- 
stood to  mean  a  sensation  referred  to  some  part  of  the  body. 
All  sensations  are  in  our  minds,  neither  in  the  body  nor  in  the 
environment ;  the  correlative  physical  states  are  in  the  body. 
The  peasant  supposes  redness,  sweetness,  heat,  &c,  to  be  in  ex- 
ternal objects,  although,  inconsistently,  he  does  not  suppose  pain 
to  be  in  the  pin  which  pricks  him.  The  physical  changes  during 
sensations  are  always  in  our  own  bodies.  The  best  classifica- 
tion of  sensations  is  into  those  which  are  objective — sensations 
referred  to,  or  as  if  standing  for,  things  in  the  environment — 
and  subjective  sensations— sensations  referred  to  the  body. 
But  this  classification,  for  obvious  reasons,  is  largely  arbitrary. 
For  an  example,  taste  serves  chiefly  subjectively,  if  it  is 
a  question  of  the  agreeable  or  disagreeable,  how  the  thing 
affects  me ;  it  serves  chiefly  objectively  when  it  is  a  question 
whether  this  thing  is  bitterer  than  that,  when  it  is  chiefly  a 
question  of  relations  of  things  outside  me  one  to  another. 

We  can  now  consider  certain  psychical  states  during  the  onset 
of  epileptic  seizures  which  are  much  more  elaborate  than  crude 
sensations.  Once  more  there  are  reasons  for  noting  in  cases  of 
epilepsy  the  side  first  in  spasm,  and  whether  the  patient  be  right 
or  left-handed.  I  speak  first  of  certain  highly  elaborate  mental 
states,  sometimes  called  "  intellectual  aurae."  I  submit  that 
the  term  "  intellectual  aura"  is  not  a  good  one.  The  state  is 
often  like  that  occasionally  experienced  by  healthy  people  as  a 
feeling  of  "reminiscence,"  that  on  which  Coleridge,  Tennyson, 
Dickens,1  and  many  others  have  written.  It  is  sometimes 
called  "  dreamy  feelings,"  or  is  described  as  "  dreams  mixing 
up  with  present  thoughts,"  "double  consciousness,"  "feeling 

1  Quotations  are  given  from  these  authors  by  Qiuerens,  a  medical  man,  who 
reports  his  own  case — epileptic  attacks  beginning  by  " reminiscence "— in  'The 
Practitioner,'  May,  1870. 


200  ON   RIGHT   OR  LEFT-SIDED   SPASM. 

of  being  somewhere  else,"  "  as  if  I  went  back  to  all  that 
occurred  in  my  childhood."  Sometimes  there  is  a  definite 
elaborate  vision.  Very  often  the  patient  is  sure  of  some 
thought,  but  cannot  describe  it  in  the  least.  Dr.  Coats,  of 
Glasgow,  has  reported  such  a  case.  The  patient  may  describe 
the  state  vaguely  as  "  silly  thoughts."  These  are  all  volumi- 
nous mental  states  and  yet  of  different  kinds ;  no  doubt  they 
ought  to  be  classified,  but  for  my  present  purpose  they  may 
be  considered  together. 

These  "  dreamy  states  "  mostly  occur  with  the  "  subjective  " 
warning  —  sensations,  smell,  and  epigastric  sensation,  and 
with  the  supposed  gustatory  movements  and  sometimes  with 
spitting.  They  cannot  be  owing  to  an  epileptic  discharge. 
It  would  be  a  remarkably  well-directed  and  distributed 
epileptic  discharge  which  would  give  rise  to  the  exceedingly 
compound  mental  state  of  being  somewhere  else.  Besides,  it 
must  not  be  forgotten  that  there  very  often  is  along  with  the 
dreamy  state  one  of  the  crude  subjective  sensations  mentioned. 
It  is  scarcely  likely  that  one  thing,  an  epileptic  discharge, 
should  be  the  physical  condition  for  a  sudden  stench  in 
the  nose — a  crude  sensation — and  also  the  physical  condition 
for  an  infinitely  more  elaborate  psychical  state.  I  submit 
that  the  former  occurs  during  the  epileptic  discharge,  and 
that  the  latter  is  owing  to  but  slightly  raised  activity  of 
healthy  nervous  arrangements  consequent  on  u  loss  of  control " 
— possibly  of  some  in  the  cerebral  hemisphere  opposite  the 
one,  which  I  believe  to  be  nearly  always  the  right,  in  which 
the  discharge  begins. 

The  elaborate  mental  state  alluded  to  occurs  sometimes 
without  any  crude  sensation  warning,  but  in  some  at  least  of 
these  cases  the  first  spasm  or  one-sided  affection  is  left.  In 
one  case,  with  the  dreamy  state,  the  patient's  head  at  the 
onset  of  every  convulsion  turned  to  the  right.  I  was  in- 
terested in  finding  that  he  was  a  left-handed  man.  This  was 
the  exception  proving  the  rule.  In  one  case,  that  of  Quserens 
(see  footnote,  p.  199),  in  which  the  patient  had  a  "remi- 
niscence," the  only  local  symptom  was  in  the  right  hand, 
and  the  patient  was  not  a  left-handed  person ;  this  case  is  a 
clear  exception. 


ON  EIGHT  OR  LEFT-SIDED.  SPASM.  201 

In  some  cases  with  the  "  dreamy  state  "  the  patient  spits. 
In  one  case  beginning  by  sensation  of  smell  the  patient  spat 
out,  and  had  no  dreamy  state.  I  suppose  the  spitting  has 
similar  significance  to  the  chewing,  &c,  movements. 

It  is,  so  far  as  I  know,  rare  for  the  dreamy  state  to  attend 
warnings  of  coloured  vision  and  noises  in  the  ear.  I  do  not 
know  of  a  clear  case  of  such  association.  This  is  the  more  re- 
markable as  each  of  these  crude  objective  sensations  is  some- 
times followed  by  a  less  elaborate  mental  state,  "  seeing  faces  " 
and  "  hearing  voices"  (words),  respectively.  "  Seeing  faces  "  is 
a  vastly  less  elaborate  state  than  the  dreamy  feelings  spoken  of, 
such  an  one  as  "  being  somewhere  else,"  although  much  more 
elaborate  than  crude  sensations.  Coloured  vision  and  "  seeing 
faces  "  are  not  likely  to  be  both  owing  to  an  epileptic  discharge. 
Both  are  psychical  states,  but  the  latter  is  far  more  elaborate. 

I  have  notes  of  but  one  case  in  which  the  dreamy  state 
occurred  with  the  objective  warning  of  definite  vertigo.1  In 
but  one  of  all  his  fits  had  this  patient  any  sort  of  warning. 
The  dreamy  state  attending  vertigo  in  that  fit  was  a  feeling  of 
being  in  some  other  place,  "  several  places,"  not  any  particular 
place.  I  use  the  expression  "  definite  vertigo,"  for  I  have  known 
two  cases  in  which  with  sensation  of  external  objects  moving 
in  front  of  the  patients,  not  to  one  side,  there  was  the  dreamy 
state ;  in  one  (the  carpenter's  case,  vide  infra)  described  as 
"silly  thoughts."  This  patient  has  the  feeling  as  if  objects 
were  coming  upon  him.  I  think  this  sensation,  and  that  of 
objects  appearing  to  move  away,  ought  to  be  distinguished 
from  the  feeling  of  objects  moving  to  one  side.  I  have  seen 
a  patient  in  whom,  according  to  his  account,  a  "  dreamy " 
feeling  did  not  occur  with  his  "  giddy  attacks,"  but  with  other 
attacks  beginning  by  some  thoracic  or  epigastric  sensation. 
So  far  the  case  is  very  striking,  and  is  particularly  so  as  to 
the  occurrence  of  mouth  movements  with  the  seizures  in 
which  there  was  the  dreamy  state.  I  admit,  however,  that 
there  are  apparently  some  discrepancies,  to  which  I  shall  try 

1  Dr.  Joseph  Coats  has  recorded  a  case,  already  alluded  to  ('  Brit.  Med. 
Journal,'  Nov.  18th,  1876),  of  an  epileptic,  each  of  whose  fits,  with  few  excep- 
tions, was  preceded  by  giddiness  and  a  peculiar  "  thought."  "  Sometimes 
the  fit  only  consists  of  the  aura,  followed  by  a  peculiar  feeling  in  the  abdomen, 
which  passes  up  to  the  head  and  back  to  the  abdomen,  when  vomiting  results." 


202  ON   RIGHT   OR   LEFT-SIDED   SPASM. 

to  give  prominence.  The  patient  recorded  his  own  case, 
which  was  published  with  additions,  some  years  ago,  by  Dr. 
Weir  Mitchell,  who  kindly  advised  him  to  see  me.  He  had 
attacks  of  several  kinds.  Weir  Mitchell  writes  :  "  The  spells 
of  pure  giddiness  have  been  frequent  of  late.  They  come 
on  suddenly,  and  there  are  none  of  the  strange  mental  con- 
ditions which  attend  the  other  spells."  The  giddiness  was 
clearly  paroxysmal,  and  was  attended  by  a  feeling  of  turning 
to  one  side.  When  I  saw  him,  I  had  no  idea  of  the  import- 
ance of  noting  the  particular  side  to  which  the  tendency  to 
turn  was,  and  had  paid  no  particular  attention  to  "dreamy 
states."  The  "  other  spells  "  began,  by  what  I  gathered  when 
I  saw  the  patient,  to  be  an  epigastric  sensation,  but  which 
he,  in  his  printed  account,  speaks  of  as  "  severe  oppression 
across  the  chest,"  making  it  difficult  for  him  to  breathe.  He 
states  in  his  account,  "  I  unconsciously  move  my  mouth  as  if 
chewing,  and  sometimes  will  also  grit  my  teeth."  He  describes 
his  mental  condition  as  comparable  to  that  of  one  suddenly 
awakened  out  of  a  sound  sleep.  "He  cannot  catch  hold  of 
the  dream,  which  seems  to  be  quickly  passing  from  him,  and 
at  the  same  time  he  cannot  yet  appreciate  the  state  of  uncon- 
sciousness into  which  he  has  so  suddenly  awakened."  He 
writes  also :  "  The  things  around  me  seem  to  be  moving  ;  and 
if  I  am  reading,  the  book  will  appear  to  be  going  from  me, 
when  at  once  I  feel  as  if  all  must  be  a  dream,  though  well 
knowing  at  the  same  time  it  must  be  reality  .  .  .  through 
it  all  the  fear  of  some  impending  catastrophe  seems  to  be 
hanging  over  me." 

Here  we  have  together  epigastric  sensation,  chewing  move- 
ments, fear,  and  dreamy  state.  But  we  have  to  note  that 
there  is  in  these  seizures  apparent  movement  of  objects ;  so 
then  it  may  be  taken  that  this  is  exceptional.  The  apparent 
movement  of  objects  of  course  implies  changes  in  himself,  some 
ocular  movements  or  discharge  of  centres  for  them.  It  may 
be  said  that  he  had  vertigo;  yet  in  what  he  himself  called 
his  giddy  fits  he  had  no  dreamy  state.  I  did  not  ascertain 
whether  the  movement  was  of  all  objects  from  him  as  it  was 
of  the  book.  When  there  is  apparent  alteration  of  the  dis- 
tance of  objects  at  the  onset  of  epileptic  seizures  they  usually 


ON   RIGHT   OR   LEFT-SIDED   SPASM.  203 

appear  to  come  nearer  or  to  be  larger,  but  may  seem  to  go 
further  off.  It  may  be  mentioned  that  on  awaking  from  sleep 
objects  appear  to  be  nearer,  and  as  we  get  fully  awake  they 
recede.  Such  apparent  displacements  of  objects  at  the  onset 
of  epileptic  seizures  no  doubt  depend  on  abnormal  states  of 
the  accommodative  apparatus  or  their  centres  (under  atropine 
objects  appear  smaller  or  further  off;  the  reverse  for  calabar 
bean).  This  is  very  different  from  displacement  of  objects  to 
one  side  attended  by  a  feeling  of  giddiness.  Lateral  move- 
ments of  the  eyes  will  have  to  do  with  estimation  of  the  figure 
(superficial  extension)  of  objects,  and  symbolise  tactual  move- 
ments ;  accommodation  has  to  do  with  distance  :  it  symbolises 
loco-motor  movements  (of  arms  as  well  as  loco-motor  move- 
ments, ordinarily  so-called). 

I  heard  of  no  one-sided  affection  in  the  attacks  with  the 
dreamy  state.  It  is  to  be  mentioned  that  he  could  talk  in 
them.  In  other  attacks,  which  he  calls  "  paralysing  attacks," 
there  was  movement  of  the  mouth;  but  he  is  then  aphasic, 
and  probably  the  movement  is  one  of  spasm.  In  these  attacks 
his  right  hand  becomes  fixed  across  his  chest,  and  he  loses 
"  all  control  over  his  words."  There  is  no  mention  of  giddiness 
in  these  seizures.  He  adds  :  "The  same  feeling  of  uncertainty 
usually  surrounds  me  as  in  the  other."  If  this  refers  to  the 
dreamy  feeling,  the  case  is  so  far  exceptional.  He  has,  however, 
attacks  of  severe  giddiness  without  any  dreamy  sensation. 

The  day  I  had  written  the  above  I  was  consulted  by  a 
right-handed  patient,  who  had  left-hemiplegia  since  1875,  and 
afterwards,  since  1876,  occasional  seizures,  like  those  of  genuine 
epilepsy.  All  his  attacks  began  by  the  same  "  dreamy " 
feeling,  as  if  he  were  falling  down  a  coal-mine.1  In  this  case 
there  was  no  other  premonitory  sensation  except  something 
referable  to  the  ear.  There  was  not,  at  the  onset,  a  sensation 
of  smell,  nor  any  epigastric  sensation,  nor  any  fear.  I  positively 
could  not  get  to  know  whether  or  not  he  had  a  noise  in  the 
ear,  or  in  the  head,  nor  even  with  certainty  that  it  was  a  noise 
at  all ;  for  the  patient,  after  describing  his  sensation  as  a 
singing,  said  it  was  not  a  real  singing,  but  rather  a  "  dulness." 

1  He  had  had  nothing  to  do  with  coal-mines  at  any  time,  and  could  discover 
no  reason  for  this  particular  recurring ."  dream." 


204  ON   RIGHT   OR   LEFT-SIDED   SPASM. 

But  the  interest  of  the  case  is  that  upon  a  damaged  right 
cerebral  hemisphere  there  should  ensue  seizures  beginning 
with  the  voluminous  mental  state  mentioned.  This  patient 
had  slight  seizures,  and  also  occasionally  severe  ones ;  in  the 
severer  ones  the  spasm  preponderated  on  the  left  side.  I  have 
('Lancet/  March  11th,  1876)  recorded  cases  in  which  noise 
in  the  ear  occurred  at  the  onset  of  epileptic  seizures ;  in  the 
second  case  this  was  followed  by  hearing  "  voices,"  a  fact, 
however,  which  was  not  mentioned  in  that  report.  I  have 
seen  many  such  cases,  but  the  case  of  the  left  hemiplegic 
patient  above  referred  to  is  the  only  one  I  have  seen  in  which 
there  was  a  voluminous  mental  state  with  a  "warning"  of 
noise ;  if,  indeed,  there  was  in  that  case  such  warning. 

There  are  other  kinds  of  psychical  states  in  connection  with 
some  epileptic  paroxysms.  It  is  not  uncommon  for  a  patient 
to  have  the  emotion  of  terror  and  to  look  terrified  at  the 
onset  of  his  seizures.  When  so,  there  is  usually  the  epigastric 
sensation  with  it.  It  is  to  be  observed  that  sometimes  there 
is  fear  without  any  epigastric  sensation,1  and  that  sometimes, 
although  very  rarely,  there  is  with  the  epigastric  sensation  a 
pleasurable  feeling.  I  never  remember  hearing  a  patient 
mention  the  antithetical  (objective)  emotion  of  anger;  but 
friends  of  patients  sometimes  describe  a  look  of  indignation. 
Yet  some  patients  say  that  at  the  onset  of  their  seizures  they 
feel  they  must  attack  some  one,  or  have  a  hatred  against 
some  person  present.  As  anger  is  the  emotion  of  combat,  this 
is  equivalent  to  confession  of  feeling  of  anger.  I  do  not  know 
anything  definite  as  to  crude  warning  sensation  with  look  of 
anger,  at  the  onset  of  epileptic  paroxysm.  Theoretically,  one 
would  expect  it  to  be  an  objective  sensation.  I  believe  that 
when  the  emotion  of  fear  occurs  at  the  onset  of  a  paroxysm, 
with  or  without  the  epigastric  sensation,  the  first  spasm  is  on 
the  left.  I  have,  however,  one  patient  whose  fits  always  begin 
by  fear — as  if,  to  use  his  words,  "  something  had  given  me  a 
sudden  fright " — and  whose  first  spasm  is  always  right-sided. 
He,  however,  is  a  left-handed   man  (his  father  is  also  left- 

1  After  some  slight  paroxysms,  beginning  either  by  the  epigastric  sensation  or 
by  fear  without  it,  the  patient's  bowels  are  moved:  a  fact,  I  submit,  of  some 
significance. 


ON   RIGHT   OR   LEFT-SIDED   SPASM. 


205 


handed).  This  patient  has  a  sensation,  not  at  his  epigastrium, 
but  at  the  middle  of  his  chest.  (The  case  has  been  referred  to, 
p.  201,  as  the  case  of  the  carpenter.) 

It  is  not  uncommon  for  a  patient  to  have  the  epigastric 
sensation,  to  look  frightened,  to  feel  frightened,  and  to  have 
also  the  dreamy  state.  In  this  regard  another  thing  is 
to  be  considered.  Some  patients  act  elaborately  after  their 
paroxysms.  I  would  ask,  "  Are  the  actions  after  the  fit, 
apparently  coloured  by  fear,  actions  of  escape,  when  the 
seizures  start  by  a  feeling  of  fear  ?  Is  the  same  emotion 
carried  out  in  each  stage  ?  " 

When  there  is  a  dreamy  feeling,  the  "dream"  also  may 
influence  the  post-epileptic  actions.  In  one  case  actions  of 
"  running  away  "  occurred  after  a  fit  beginning  by  sensation 
of  smell,  and  with  a  "  feeling  of  being  somewhere  else." 
Another  patient  always  used  to  run  away  after  fits,  at  the  onset 
of  which  she  had  the  feeling  of  "  being  miles  away."  (Cor- 
respondingly for  spectral  faces,  voices,  &c,  after  coloured  vision 
and  noises  in  the  ear  ?)  As  with  the  epigastric  sensation  and 
fear  there  is  often  also  a  "  dreamy  "  state,  we  may  have  actions 
in  accord  with  the  "dream,"  and  also  coloured  by  fear.  I 
imagine  the  actions  in  some  cases,  wherein  there  is  the  dreamy 
feeling,  except,  perhaps,  that  of  reminiscence  (which  is,  I 
presume,  nothing  other  than  a  revelation  of  the  earlier  sub- 
conscious part  of  the  normal  process  of  recognition),  are  more 
likely  to  be  adjustments  to  some  "  ideal  "  environment ;  the 
dream  being  made  up  chiefly  of  long-past  experiences ;  the 
actions  may  be  very  elaborate  and  yet  not  purposive-looking 
as  to  the  present  environment. 

I  would  suggest  a  corresponding  series  of  inquiries  as  to 
seizures  beginning  by  objective  sensations,  and  especially  by 
vertigo.  "  Are  the  actions  after  these  seizures  more  seemingly 
purposive  to  the  patient's  present  surroundings,  and  often  those 
of  anger  ?  "  "  Are  they  the  result  of  an  '  unreinembered ' 
or  vaguely  remembered  *  dream,'  made  up  chiefly  of  recent 
experiences  ?  "  The  expression  "  unreinembered  dream  "  may 
seem  absurd  at  first  glance ;  but  we  must  bear  in  mind  that 
Descartes,  Leibnitz,  Kant,  Jouffroy,  and  Hamilton  believed 
there  to  be  no  dreamless  sleep.     It  may,  however,  be  held  that 


206  ON   EIGHT   OK   LEFT-SIDED   SPASM. 

there  is  nervous  activity  without  any  attendant  mental  state 
in  deep  sleep,  that  it  is  really  dreamless,  and  that  any  "  mental 
modifications"  come  during  waking.  Similarly  it  may  be 
held  that  when  actions  after  a  fit  are  very  purposive-looking 
there  is  no  "  dream,"  but  yet  such  kind  of  activity  of  nervous 
arrangements  as  would  in  imperfect  sleep  give  rise  to  a  dream, 
made  up  chiefly  of  recent  experiences. 

When  actions  are  always  the  same  in  a  patient  after  every 
fit,  it  may  be  that  they  are  in  accord  with  what  occurred  about 
the  time  of  his  first  seizure. 

To  repeat.  I  ask,  on  which  side  is  the  first  spasm,  or  other 
abnormal  condition,  in  cases  beginning  by  crude  sensation  of 
smell,  by  movements  of  chewing,  &c,  by  the  epigastric  sensa- 
tion with  or  without  fear,  and  in  cases  where  there  is  fear 
without  any  epigastric  sensation  ?  I  think  it  is  usually  the  left 
side.  Again  I  ask,  on  which  side  is  the  first  spasm,  or  other 
abnormal  condition,  when  there  is  a  "  dreamy  state "  with  or 
without  any  of  the  above-mentioned  phenomena  ?  I  think  it 
is  usually  the  left.  We  ought  to  inquire  also  whether  the 
patient  be  left  or  right-handed.  Correspondingly  for  cases  in 
which  there  is  a  crude  objective  sensation  as  a  warning. 

I  would  ask  also  that  the  nature  of  the  actions,  when  they 
occur  after  a  fit,  should  be  considered  (a)  as  being  complex 
or  simple ;  (h)  as  purposive-looking,  or  seemingly  purposeless ; 
(c)  as  unemotional,  or  as  coloured  by  anger  or  fear. 

I  doubt  not  that  there  is  some  order  throughout,  from  the 
warning  to  the  end  of  the  post-paroxysmal  stage.  The  above 
imperfect  sketch,  the  best  I  can  do,  is  the  result  of  much 
labour,  as  a  contribution  towards  discovering  this  order.  I  am 
far  from  asserting  that  I  have  done  anything  of  value  towards 
this  end,  and  trust  I  have  fairly  acknowledged  the  difficulties 
and  uncertainties  necessary  to  investigations  in  which  we  have 
to  trust  so  much  to  our  patients. 


NOTES  ON  LEFT-HANDEDNESS. 

BY   WILLIAM   W.   IKELAND,   M.D., 
Med.  Superintendent  Scot.  Nat.  Inst,  for  Imbecile  Children,  Larbert. 

My  attention  was  directed  to  the  subject  of  left-handedness  by  a 
series  of  articles  by  Mr.  Charles  Keade.  The  view  advocated  by 
this  writer  was  that  naturally  the  left  hand  is  as  readily  used 
as  the  right,  but  that  inveterate  custom  has  led  men  to  give  an 
arbitrary  preference  to  the  right  as  the  hand  which  uses  the 
sword,  while  the  left  is  condemned  to  bear  the  shield.  He 
attributes  the  comparative  awkwardness  with  which  the  left 
hand  is  used  to  the  great  care  which  women  take  in  infancy 
to  accustom  children  to  use  the  right  hand  in  all  difficult 
operations  which  require  only  one  arm  for  their  use.  Certain 
it  is  that  infants  seem  at  first  to  use  both  hands  indiscrimi- 
nately, and  the  one  arm  seems  to  be  at  first  as  well  developed 
as  the  other,  though  in  process  of  time  the  right  arm  gets 
more  muscular  than  the  left.  It  is,  however,  difficult  to  under- 
stand how  all  nations  and  tribes,  without  exception,  have  in 
all  times  of  which  we  know  anything  given  the  preference  to 
the  right  hand,  unless  they  have  got  some  natural  reason  for 
so  doing,  independently  of  arbitrary  usage.  Anatomists  have 
pointed  out  a  slight  lateral  curvature  of  the  vertebral  column 
in  the  dorsal  region,  the  convexity  of  which  is  turned  towards 
the  right  side,  and  some  have  attributed  the  preference  given 
to  the  right  arm  to  this  bend  or  curve  of  the  right  side.  It  is, 
however,  more  likely  the  effect  than  the  cause  of  right-handed- 
ness, a  deviation  caused  by  muscular  action,  as  explained  by 
Bichat.  As  most  persons  are  disposed  to  use  the  right  arm  in 
preference  to  the  left,  the  body  is  curved  to  the  left  when 
making  efforts,  as  in  pulling,  for  the  purpose  of  giving  an 


208  NOTES   ON   LEFT-HANDEDNESS. 

additional  advantage  to  the  muscles,  and  enabling  them  to  act 
with  more  power  on  the  points  to  which  they  are  attached, 
and  the  habitual  use  of  this  position  gives  rise  to  some  degree 
of  permanent  curvature.  In  support  of  this  explanation  of 
the  fact,  Beclard  has  stated  that  he  found  in  one  or  two 
individuals  who  were  known  to  have  been  left-handed,  the 
convexity  of  the  lateral  curve  directed  to  the  left  side. 

On  making  inquiry  in  the  September  of  last  year,  which  was 
done  at  the  request  of  Dr.  Crichton-Browne,  who  was  interested 
in  the  subject,  I  found  that  there  were  in  the  Institution 
78  children,  49  males  and  29  females,  who  were  using  their 
right  hands  normally.  There  were  14  boys  and  9  girls,  23  in 
all,  who  appeared  to  use  indiscriminately  either  the  right  or  the 
left  hand ;  while  7  boys  and  6  girls,  13  in  all,  were  decidedly 
left-handed.  On  going  over  our  pupils  this  year,  it  was  found 
that  we  had  53  males  and  31  females  who  were  right-handed ; 
that  11  boys  and  7  girls,  18  in  all,  used  either  hand  indis- 
criminately; while  9  boys  and  7  girls,  16  in  all,  were  decidedly 
left-handed.  Three  girls  had  ceased  to  be  left-handed  during 
the  year,  that  is,  they  now  use  the  right  hand  for  sewing  and 
working,  where  formerly  they  did  the  left. 

Wishing  to  ascertain  how  many  left-handed  there  were 
among  ordinary  children,  I  applied  to  Mr.  Paterson,  the 
teacher  of  the  Sessional  School  in  Larbert,  who  communicated 
to  me  the  following  observations.  Amongst  54  children,  whose 
ages  ranged  from  4  to  7  years,  8  children  had  come  to  school 
left-handed.  They  were  not  allowed  to  use  their  left  hands  in 
writing  or  ciphering.  Great  trouble  had,  in  fact,  been  taken  to 
make  them  desist  from  using  their  left  hands.  Some  of  them 
had  to  be  kept  near  the  teacher  at  their  writing,  but  in  the 
playground  they  threw  stones  and  played  at  bowls  with  their 
left  hands.  It  was  thought  that  left-handedness  seemed  more 
prevalent  with  children  likely  to  be  neglected  in  infancy,  but 
this  could  not  hold  good  of  two  of  the  eight.  These  children, 
originally  left-handed  but  now  trained  to  write  with  the  right 
hand,  were  not  less  expert  than  the  rest,  and  two  of  them  were 
extra  good  writers.  Of  104  older  children  out  of  52  families 
6  boys  and  5  girls  were  left-handed ;  that  is  to  say,  they  used 
the  left  hand  at  play,  but  in  the  school  wrote,  or  were  made  to 


NOTES   ON   LEFT-HANDEDNESS.  209 

write,  with  their  right  hands.  In  the  whole  school,  out  of  70 
girls,  11  girls  were  left-handed ;  and  out  of  88  boys,  8  were 
left-handed.  Thus  there  was  a  percentage  of  15  girls  and  9 
boys  who  were  left-handed ;  and,  putting  both  sexes  together, 
19  out  of  158,  that  is,  12  per  cent.  In  1878  the  proportion  of 
left-handed  amongst  our  idiots  was  11  per  cent.,  somewhat  less 
than  in  the  Sessional  School ;  and  in  1879  the  proportion  was 
of  boys  left-handed,  12  per  cent. ;  of  girls,  15  per  cent. ;  of  boys 
and  girls  together,  13  per  cent.  From  this  it  appears  that  left- 
handedness  is  not  more  frequent  with  imbeciles  than  with  normal 
children.  But  the  cases  amongst  the  imbeciles  were  much  more 
decided  in  their  left-handedness,  generally  using  their  left 
hands  for  all  purposes ;  and  in  the  Sessional  School  the  children 
were  all  classified  as  left  or  right-handed;  whereas  in  the 
Institution  there  is  a  class  as  large  as  the  left-handed  who  use 
both  hands  indiscriminately.  I  am  aware  of  the  objection 
to  having  such  an  intermediate  class,  but  it  was  felt  impossible 
fairly  to  state  these  children  as  either  right  or  left-handed. 

Thus  in  the  Institution  at  present,  15  per  cent,  both  of  the 
boys  and  the  girls  use  their  right  hand  or  their  left  hands 
indiscriminately.  So  if  there  are  no  more  imbecile  children 
decidedly  left-handed,  there  is  a  much  smaller  percentage  of 
children  who  are  decidedly  right-handed;  for  while  of  the 
normal  children  in  the  Sessional  School  88  per  cent,  were 
right-handed,  of  the  imbecile  children  now  in  the  Larbert 
Institution  only  72  per  cent,  were  decidedly  right-handed. 

As  idiot  children  are  much  less  tractable  than  other 
children,  and  it  is  much  more  difficult  to  teach  them  to  use 
their  limbs  properly,  these  results  would  probably  be  considered 
by  Mr.  Beade  as  confirming  his  theory ;  and  it  is  difficult  to 
deny  that  custom  has  a  certain  power  in  inducing  all  those 
who  have  a  weak  tendency  to  prefer  their  left  hand,  to  make 
use  of  their  right  one  instead.  Some  people  who  have  been 
left-handed  in  infancy,  and  who  through  persevering  education 
have  been  made  to  use  their  right  hand  for  acquired  work 
still  continue  to  use  their  left  leg  preferably  to  their  right ; 
for  example,  in  kicking,  or  setting  off  down  a  slide. 

Luys  has  asserted  that  the  left  side  of  the  brain  is  earlier 
developed  than  the  right,  so  that  the  left  hemisphere  in  the 

vol.  in.  P 


210  NOTES   ON   LEFT-HANDEDNESS. 

new-born  child  is  a  few  grammes  heavier  than  the  right ;  and 
in  the  adult  the  right  hemisphere  has  been  found  generally 
to  weigh  heavier.  If  this  observation  of  Luys  be  correct,  the 
superior  weight  of  the  left  hemisphere  at  birth  might  be  held 
to  confirm  as  well  as  to  account  for  the  habitual  preference 
given  to  the  right  limbs.1  Moreover,  if  the  head  be  carefully 
examined,  it  will  be  found  that  its  contour  is  rarely  sym- 
metrical on  both  sides.  There  is  generally  a  greater  protuberance 
on  the  left  side,  a  little  above  or  behind  the  ear,  than  on  the 
right.  On  the  left  side  we  have  a  greater  curve  than  on  the 
right,  the  right  side  being  flatter.  This  would  indicate  a 
greater  development  of  the  brain  on  the  left  side,  near  the 
region  where  physiologists  have  placed  the  motor  area  of 
the  brain. 

In  order  that  there  should  be  less  chance  of  error,  I  took 
the  cranial  outlines  of  the  heads  of  our  inmates  with  a 
conformateur.  The  bulging  above  or  behind  the  ear  in  the 
left  side  was  found  to  prevail.  A  very  common  form  of  the 
head  was  a  bulge  on  the  left,  behind  or  above  the  ear,  and  a 
bulge  on  the  right  side  in  front,  at  the  angle  of  the  forehead. 
Thus  the  greater  size  of  the  left  posterior  region  is  made  up 
to  a  certain  degree,  by  bulging  on  the  right  anterior  angle. 
Most  of  those  had  a  bulge,  or  increased  curvature,  on  the  right 
side,  above  or  behind  the  ear ;  but  this  did  not  hold  good  of 
all  cases. 

In  a  few  instances  of  left-handedness  there  was  very  little 

1  Since  writing  this  paper  I  have  had  an  opportunity  of  examining  two  cases 
which  may  bear  on  the  subject.  B.  N.,  11  years  old,  epileptic  imbecile,  left- 
handed  from  early  infancy,  and  subject  to  very  frequent  fits,  which  are  occasion- 
ally on  right  side  only,  when  he  retains  consciousness  and  is  able  to  answer 
questions.  About  8  months  before  death  he  had  these  partial  fits,  followed  by 
temporary  paralysis  of  right  arm,  which  also  implicated  the  face.  Died  appa- 
rently from  exhaustion,  following  repeated  general  convulsions.  Whole  surface  of 
cerebrum  deeply  injected,  bright  red,  with  patches  of  deeper  hue.  The  left  side 
of  encephalon  was  smaller  than  the  right.  This  wa3  especially  noticeable  in  the 
middle  lobe,  viewed  from  below,  and  the  middle  fossa  of  skull  was  smaller.  The 
pons  was  also  smaller  on  the  left  side.  The  right  side  of  encephalon  weighed 
20f  oz. ;  the  left  side  15£  oz.  H.  M.,  paralytic  imbecile,  hud  a  second  shock  after 
coming  to  institution,  aggravating  the  old  paralysis  of  the  right  side.  Lingered 
on  for  a  year  in  great  debility,  sinking  into  deep  dementia.  The  cortex  of  cere- 
brum was  much  diseased  and  wasted,  witli  adherent  membranes  and  accumulation 
of  fluid  within  the  ventricles.  The  right  side  of  brain  weighed  16}  oz. ;  the  left 
weighed  15  oz. 


NOTES  ON   LEFT-HANDEDNESS.  2U 

difference,  in  others  there  was  actually  a  bulging  on  the  left 
side.  Putting  aside  the  cranial  outlines  of  those,  the  surface 
of  whose  heads  were  bigger  on  the  right  side,  I  found  that  7 
were  decidedly  left-handed,  7  belonged  to  the  indiscriminate 
class,  and  10  were  right-handed.  Of  those  whose  outline 
seemed  larger  on  the  left  side,  5  were  decidedly  left-handed, 
8  indiscriminate,  and  50  right-handed.  One  girl,  who  was 
very  decidedly  left-handed,  was  much  bigger  on  the  left  side. 
In  one  boy,  almost  a  mute,  but  with  so  much  intelligence  that  he 
might  be  styled  an  aphasic  imbecile,  and  who  was  left-handed, 
the  greater  size  of  the  left  side  of  the  head  was  very  decided. 
Those  who  are  left-handed  generally  kick  with  the  left  foot,  but 
not  always.  I  have  the  cranial  outline  of  a  man  who  was  left- 
handed  in  childhood,  but  who  was  trained  to  work  at  a  trade 
with  his  right  hand.  In  his  case  the  bulging  in  the  head  is 
on  the  left  side.  On  taking  the  cranial  outline  of  a  friend,  I 
remarked  that  he  ought,  from  the  contour  of  his  head,  to  be 
left-handed.  He  answered  that  he  could  use  both  hands 
almost  equally  well,  and,  as  a  proof  of  it,  wrote  his  name  upon 
the  profile  card  with  his  left  hand.  He  observed  that  his 
father  had  been  left-handed,  and  I  have  met  with  other  facts 
which  make  me  think  that  it  is  worth  while  inquiring  whether 
this  peculiarity  may  not  be  hereditary. 

It  is  but  fair  to  acknowledge  that  I  am  indebted  to  Mr. 
Crochley  Clapham  for  the  idea  of  using  the  conformateur  in 
this  line  of  inquiry.  This  able  anthropologist  has  stated,  as 
the  result  of  his  extensive  inquiries,1  "  that  the  most  common 
form  of  skull  met  with  was  that  having  its  greatest  transverse 
diameter  posterior  to  the  median  line,  and  being  most  pro- 
tuberant, with  reference  to  the  long  diameter,  on  the  left  side. 
This  condition  of  left-handedness  was  present  in  81*771  per 
cent,  of  the  insane ;  but,  as  shown  in  the  regional  development 
table,  was  much  more  marked  in  some  diseases  than  in  others ; 
and,  as  bearing  upon  the  question  of  which  is  the  '  driving 
side '  for  convulsions,  it  may  be  interesting  to  notice  that  left- 
handedness  is  not  only  very  common  in  epilepsy,  but  is  also 

1  See  the  paper  on  "  The  Cranial  Outline  of  the  Insane  and  Criminal,"  by 
Crochley  Clapham,  L.R.C  P.,  &c,  and  Henry  Clarke,  L.R.C.P.,  &c.,  in  the  '  West 
Riding  Asylum  Reports,'  vol.  vi.  p.  154. 

p  2 


212  NOTES   ON   LEFT-HANDEDNESS. 

more  pronounced  in  this  disease  than  in  any  other  form  of 
mental  affection."  Mr.  Clapham  also  observes  that  the  "  nume- 
rical superiority  of  the  left-'  headed '  agrees  with  observations 
made  by  numerous  writers  on  the  greater  relative  weight  of 
the  left  cerebral  hemisphere.  That  it  has  an  obvious,  though 
by  no  means  exclusive,  connection  with  right-handedness  is 
shown  on  comparing  the  criminal  tables,  where  the  opposite 
state  of  right-headedness  was  exhibited  in  a  number  of  left- 
handed  individuals."  Some  may  hold  that  this  one-sided  de- 
velopment of  the  brain  is  really  the  consequence  not  the  cause 
of  right-handedness,  that  just  as  the  right  arm  becomes  stronger 
and  more  muscular  than  the  left  by  constant  use,  the  correspond- 
ing portion  of  the  brain  also  takes  an  increased  development. 

The  view  that  the  habitual  preference  of  the  right  arm 
really  arises  from  a  greater  or  earlier  innate  power  in  the  left 
hemisphere,  seems  strengthened  by  the  well-known  facts  of 
aphasia,  and  the  physiological  experiments  confirming  and 
illustrating  them. 

It  is  scarcely  needful  to  recall  that  on  the  left  side  of  the 
brain  in  the  lower  part  of  the  third  frontal  convolution,  or  in 
the  operculum,  is  situated  what  has  been  called  the  speech- 
centre,  where  motor  acts  of  articulation  take  their  origin.  On 
the  destruction  of  these  parts  on  the  left  side,  the  power  of 
imitating  words  is  lost,  though  the  aphasic  patient  generally 
understands  words.  As  the  utterance  of  words  requires  the 
combined  action  of  both  right  and  left  muscles  of  the  vocal 
apparatus,  it  is  clear  we  have  here  a  fair  case  of  one-sidedness 
in  the  hemispheres,  which  can  only  be  denied  by  denying  that 
in  most  cases  of  aphasia  the  lesion  is  on  the  left  side,  and  that 
it  is  often  associated  with  paralysis  of  the  right  arm.  This 
left-sidedness,  at  any  rate,  is  beyond  the  reach  of  mothers  and 
teachers. 

Dr.  Ferrier  observes,  in  his  book  on  the  '  Functions  of  the 
Brain ' : 1  "As  regards  the  articulating  centres,  the  rule  seems 
to  be  that  they  are  educated,  and  become  the  organic  seat  of 
volitional  acquisitions  on  the  same  side  as  the  manual  centres. 
Hence,  as  most  people  are  right-handed,  the  education  of  the 
centres  of  volitional  movements  takes  place  in  the  left  hemi- 

1  Page  278. 


NOTES  ON  LEFT-HANDEDNESS.  213 

sphere.  This  is  borne  out  in  a  striking  manner  by  the  occur- 
rence of  cases  of  aphasia  with  left  hemiplegia  in  left-handed 
people.  Several  cases  of  this  kind  have  now  been  put  on 
record." 

An  instance  is  given  by  Dr.  Hughlings-Jackson,1  who 
adds  : — "  It  is  admitted  that  these  are  cases  of  left  hemiplegia 
with  aphasia  in  persons  who  are  not  left-handed."  In  such 
cases  we  must  suppose  the  main  articulating  centre  to  have 
been  in  the  right  hemisphere  without  inducing  the  motor 
centre  of  the  left  arm  to  take  the  lead.  This  seems  to  prove 
that  the  connection  of  sequence  or  concomitance  between  the 
education  of  the  centres  of  articulation  and  manual  execution 
in  the  same  side  of  the  brain  is  at  least  not  inseparable. 
As  a  rule  the  left  hemisphere  seems  functionally  the  most 
active,  though  the  right  side  has  also  its  work,  and  the  left 
hand  executes  important  actions,  such  as  holding  the  reins 
on  horseback. 

Mr.  Crochley  Clapham  has  noticed  that  left-handedness  is 
more  marked  in  men  than  in  women,  which  "goes  to  sub- 
stantiate the  '  crossed-action '  theory,  as  most  female  employ- 
ments necessitate  the  pretty  even  use  of  the  two  hands." 

Dr.  Wilbur,  of  Syracuse,  New  York,  had  a  friend  who 
professed  to  be  able  to  distinguish  a  left-handed  man  from  a 
right-handed,  by  attentively  watching  him  without  seeing 
him  make  any  special  use  of  the  arm.  He  grounded  his 
observations  on  the  premise  that  the  appearance  of  the  face 
was  also  different  in  the  left-handed.  Certainly,  the  configu- 
ration of  the  face  and  the  fulness  of  the  facial  muscles  often 
vary  a  little  on  each  side ;  but,  as  far  as  my  observations  go, 
I  am  not  prepared  to  undertake  the  challenge  sustained  by 
Dr.  Wilbur's  friends. 

Trousseau2  has  remarked  that  the  right  and  left  sides  are 
subject  to  different  diseases.  Neuralgia  is  so  much  commoner 
on  the  left  side,  that  for  three  years  during  which  he  kept 
notes  he  did  not  observe  a  single  example  of  it  on  the  right 
side  of  the  chest,  when  real  neuralgia  was  carefully  distin- 
guished from  pleurodynia,  pleuritic  stitches,  and  hepatic  colic. 

1  « Brain,'  October,  1879,  p.  329. 

2  '  Clinique  Medicale,'  Paris,  1868,  vol.  ii.  p.  668. 


214  NOTES   ON   LEFT-HANDEDNESS. 

It  may  be  asked,  that  Where  left-handedness  has  shown 
itself  in  a  decided  manner,  is  it  proper  that  so  much  trouble 
should  be  taken  to  make  the  child  break  it  off?  By  so  doing 
it  is  evident  that  the  teacher  gives  the  child  a  great  deal  of 
trouble  and  perplexity.  A  left-handed  child  forced  to  write 
with  his  right  hand  through  fear  of  punishment,  is  very  much 
in  the  same  condition  as  a  right-handed  one  who  should  be 
forced  to  hold  his  pen  in  his  left.  There  is  no  proof  that 
people  who  remain  decidedly  left-handed  all  their  lives  are 
less  skilful  with  their  hands  than  others.  One  of  the  earliest 
mention  of  left-handedness  is  in  the  book  of  Judges,  where  it 
is  recorded  that  amongst  the  26,700  fighting  men  of  the  tribe 
of  Benjamin,  there  were  700  chosen  men  left-handed ;  every 
one  could  sling  stones  at  a  hair-breadth,  and  not  miss. 

On  the  other  hand,  it  may  be  argued  that  as  those  who  are 
originally  left-handed  generally  retain  the  use  of  their  left 
hands  for  a  number  of  offices,  by  teaching  them  to  use  their 
right  hand  we  are  to  a  certain  extent  making  them  ambidex- 
trous. Another  consideration  seems  much  less  capable  of  dis- 
pute ;  since  custom  has  clearly  so  much  play  in  determining 
what  hand  shall  be  used,  it  is  a  misfortune  when  our  acquired 
expertness  becomes  the  exclusive  property  of  one  hand.  We 
ought  to  practise  the  left  hand  as  well  as  the  right  in  difficult 
manoeuvres.  There  is  no  doubt,  for  example,  that  it  is  of 
great  advantage  for  a  surgeon  to  be  skilful  in  the  use  of  both 
hands,  and  this  can  be  only  obtained  by  practice  commenced 
in  early  years. 


Critical  $\iQtstB  ann  Sottas  of  |kafcs. 

The  Brain  as  an  Organ  of  Mind.  By  H.  Charlton  Bastian, 
M.D.,  F.R.S.,  &c.  Kegan  Paul  &  Co.,  London.  International 
Series,  1880. 

The  taking  title  of  this  book  at  once  suggests  the  question  or 
questions,  what  is  the  brain  ?  what  is  mind  ?  and  what  is  an 
organ  ?  and  if  they  do  not  meet  with  a  clear  response,  it  is  not 
from  any  want  of  inclination  or  ability  on  the  part  of  the 
author  to  deal  with  them  in  the  fullest  manner  which  scientific 
knowledge  will  permit.  Dialectic  skill,  the  heritage  of  meta- 
physicians, is  more  and  more  shared  by  these  new  rivals,  who 
are  more  formidable  than  the  older  antagonists  the  pure 
physicists  ;  rivals  whose  forcible  endeavour  is  to  prove  the  cor- 
relation of  all  knowledge,  and  in  this  domain  especially  to  cor- 
relate those  ancient  foes,  metaphysics  and  physiology.  Surely 
nothing  in  these  days  can  be  more  narrow  and  misleading 
than  for  the  metaphysicians  to  exclaim,  "  Oh,  that  is  physi- 
ology, we  have  nought  to  do  with  that,"  unless  it  be  a  like 
response  from  the  physiologist  in  his  ignorant  abuse  of  the 
methods  of  metaphysics.  It  is  no  wonder  that  the  elder 
science,  which  attained  to  the  perfection  of  Aristotle  and  Plato 
when  real  knowledge  of  living  organisms  was  barely  commenced, 
should  have  stood  alone  in  sulky  dignity  long  after  it  ought 
to  have  welcomed  the  alliance  of  the  new  power.  Nor  is  it 
inexplicable  that  physiologists  should  tend  towards  exclusive- 
ness  in  their  attempts  to  answer  all  the  problems  of  life  by 
their  own  methods.  But  now  that  the  sciences  are  continually 
being  differentiated  and  multiplied  does  it  become  the  more 
needful  to  appreciate  their  essential  correlation ;  and  in  none 
so  much  as  in  the  sciences  of  mind,  and  that  science  of  living 
organisms  without  which  mind,  so  far  as  we  know,  cannot  exist. 


216  CRITICAL   DIGESTS  AND 

And  when  we  speak  of  these  sciences  of  mind,  which  developed 
into  activity  long  before  a  nerve-cell  or  tube  had  ever  been 
seen  or  imagined,  we  mean,  not  simply  the  abstract  sciences  of 
ethics  or  metaphysics,  or  that  guess-work  of  immaterial  ontology 
which  it  may  still  amuse  some  to  maintain  and  some  to  decry 
with   equal    impotence    and    futility,   but   of  those    concrete 
sciences  of  poetry  and  history,  and  all  those  literse  humaniores 
which  teach  us  so  much  of  what  we  know  of  the  motives  and 
actions  of  man,  and  without  which  the  knowledge  of  the  whole 
mass  of  physical  science  would  be  poor  indeed.     Conceive  the 
great  Chinese  nation  having  got  the  start  of  all  the  world  by 
a  thousand  years  in  the  art  and  science  of  physiology,  as  they 
did  in  those  of  the  fictile  manufactures !     Clearly  they  might 
have  attained  to  a  knowledge  which  we  can  scarcely  imagine 
of  the  physical  processes  of  sensation,  emotion,  and  memory, 
while  they  remained  the  children  they  are  in  the  real  science 
of  mind  and  motive.     And   this   is   what   our   physiologists 
might  do,  if  their  labours  did  not  constantly  fecundate  other 
knowledge,  which  again  gratefully  repays  its  debts  in  adding 
force  and  breadth  to  their  own  powers  in  their  own  domains. 
Dr.  Bastian  is  an  excellent  example  of  this  modern  combination 
of  the  dialectician  with  the  physicist,  and  his  book  is  a  good 
instance  of  the  correlation  of  metaphysics  with  physiology — 
leaning,  it  is  true,  to  the  latter  with  a  heavy  bias,  but  frankly  ac- 
cepting the  more  abstract  science  in  all  except  its  unintelligible 
and  indeed  inconceivable  ontology.     It  is  somewhat  intriguing 
to  one's  curiosity  that  writers  like  Bastian  and  Bain  should 
think   it    worth   their   while   to    continue    these    arguments 
against  an  ontological  essence  of  mind,  while  the  very  idea  of 
such  a  thing  remains  unpresentable  to  the  mind,  and  when 
it  seems  to  be  certain  that  belief  in  such  a  thing  is  belief  in  a 
verbal  formula,  and   not  in  a  real   idea.     Dr.  Bastian  com- 
mences with  an  interesting  chapter  on  the  Uses  and  Origin 
of  a  Nervous  System.     As  might  be  expected  from  his  well- 
known  views  on  the  beginnings  of  life,  this  chapter  contains 
opinions  which  are  not  generally  accepted.     Dr.  Bastian  as- 
sumes that  it  is  "  commonly  admitted  that  many  of  the  lowest 
forms  of  life  cannot  positively  be  assigned  either  to  the  vege- 
table or  the  animal   kingdom,"  "  creatures  of  circumstance," 


NOTICES  OP  BOOKS.  ^      217 

among  whom  "  variability  reigns  supreme,"  "  appearing  now 
as    animals,    now   as    plants,"    which   he   designates   "  ephe- 
meromorphs."     Modes  of  growth,  he  says,  have  been  observed 
to   occur    in    them   with   frequent   and   rapid   changes    from 
vegetable  to  animal,  and  from  animal  to  vegetable;  and  he 
compares  these  changes  to  the  well-known  metamorphoses  of 
form  and  nature  amongst  simpler  kinds  of  matter,  as  in  the 
changes  from  the  crystalloid  to  the  colloid  form  of  molecular 
aggregation  demonstrated  by  Graham,  and  to  the  interchange- 
able states  of  carbon,  phosphorus  and  sulphur.     While  we  take 
the  author's  word  for  the  peculiar  qualities  of  his  ephemero- 
morphs,  the  analogy  to  the  allotropism  of  inorganic  elements 
seems  forced,  and  the  manner  in  which   these  considerations 
lead  through  the  movements  of  plants  to  those  of  animals,  and 
to  the  differentiation  of  nerve  tissue,  is  not  very  obvious  or  con- 
vincing.    No  doubt  it  is  right  to  begin  at  the  beginning,  and 
to  seize    the  first    link  of  the  chain    if  we  can,  but    many 
physicists  will  think  that  there  are  some  important  links  wanting 
between  allotropic  sulphur  and    the  Amoebae — "  the  simplest 
types  of  unquestionable  animal   life"   with   "high   inherent 
activity,"  and  with  "  the  power  of  executing  well-marked  in- 
dependent movements,  and  of  feeding  upon  solid  food."     Most 
people  will  even  think  that  there  is  an  important  link  wanting 
between  the  allotropic  chemical  and  the  self-multiplying  Con- 
fervae,  and  another  between  them  and  the  amoeba,  with  its 
high  inherent  activities  and  independent  movements. 

With  independent  movements  and  "the  selective  power 
which  the  amoeba  seems  to  manifest,"  we  first  appear  really 
to  touch  upon  the  problem  of  mind,  for  we  are  supposed  to  be 
within  the  confines  of  science,  so  that  any  misgivings  as  to  the 
mind  of  the  inorganic  universe,  or  even  the  loves  of  the  plants, 
must  be  excluded.  But  what  do  the  independent  movements 
of  the  amoeba  in  the  selection  of  food  mean  ?  Probably  the 
author  will  concede  that  in  a  certain  sense  no  movements  even 
the  most  voluntary  of  the  highest  known  organism  are  really 
independent ;  for  whether  the  will  be  determined  or  not,  the 
movements  it  ordains  are  determined,  and  are  therefore  not 
independent.  But  in  a  milder  sense  the  movements  of  the 
amoeba  may  well  be  supposed  to  be  far  less  dependent  upon 


218  CRITICAL   DIGESTS   AND 

outward  circumstance  than  those  of  the  insectivorous  plants, 
and,  indeed,  to  indicate  the  high  inherent  activities  here 
attributed  to  them.  And  what  can  the  inherent  conditions 
be  in  which  these  inherent  activities  develope  unless  it  be  the 
first  dim  glimmering  of  consciousness,  a  condition  analogous,  if 
not  homologous,  to  our  own  consciousness  ?  That  no  one 
can  positively  affirm  this  to  be  so  or  not  to  be  so,  is  as  true  of 
the  amoeba  as  of  the  crayfish,  of  which  Huxley  rightly  says 
that  without  being  a  crayfish,  or  at  least  having  been  a  cray- 
fish and  remembering,  no  one  can  say  whether  it  is  conscious 
or  not.  But  the  same  may  be  said  of  the  author  himself. 
One  can  only  draw  the  "  legitimate  inference  "  that  he  is  con- 
scious. One  can  by  no  means  claim  any  positive  knowledge 
that  he  is  conscious.  This,  however,  also  would  appear  to  be  a 
legitimate  inference,  that  when  an  organism,  however  lowly, 
shows  by  independent  movements  in  the  selection  of  food  that 
it  possesses  inherent  activities,  it  is  probable  that  it  distinguishes 
between  the  being  which  selects  and  the  food  selected  ;  that  is 
to  say,  between  the  me  and  the  environment,  the  ego  and  the 
non-ego  ;  and  if  this  be  not  consciousness,  we  can  form  no  con- 
ception of  what  it  is,  or  of  what  rudimentary  consciousness 
itself  may  be.  This  inference,  which  to  many  may  appear 
forced  and  unwarranted,  the  author  does  not  draw,  however 
near  the  quoted  terms  he  has  employed  may  seem  to  lead  to 
it.  For  ourselves  we  abide  by  it  as  a  legitimate  inference 
from  the  continuous  chain  of  organisms  in  which  there 
appears  to  be  no  break  in  consciousness.  And  if  it  be  said 
that  in  the  amoeba  and  other  of  the  very  simplest  animal 
organisms  there  is  no  separate  organ  of  consciousness,  it  may 
be  replied  that  we  have  no  proof  that  such  a  separate  organ  is 
necessary  for  the  purpose ;  and  for  that  matter  that  the  amoeba 
may  as  well  be  considered  a  nerve-cell  with  powers  of  digestion 
as  a  digestive  cell  with  nervous  function.  Our  author's  views 
as  to  the  states  of  consciousness  of  the  lower  animals  are 
much  more  restricted.  He  thinks  that  even  the  opinion  of 
Gr.  H.  Lewes,  that  all  nerve  centres  are  the  seats  of  nervous 
sensibility,  "  would  only  lead  to  its  extension,  and  soon  make 
it  almost  impossible  to  deny  a  similar  attribute  to  the  leaves  of 
the  sun-dew  and  other  sensitive  plants,  or  indeed  to  stop  even 


NOTICES  OF  BOOKS.  219 

here.  Endless  confusion  might  thus  be  produced  without 
commensurate  gain."  But  no  one  can  believe  that  any  plant 
is  really  possessed  of  sensation,  although  called  sensitive  ;  and 
the  motive  of  immediate  profit  or  loss  to  science  ought  never 
to  be  considered,  for  nature  gives  long  credit  to  drafts  upon 
her  resources  which  may  at  first  seem  untrustworthy.  When 
Dr.  Bastian  states  that  "  the  very  existence  in  the  lower 
animals  of  any  conscious  states  analogous  to  those  which  we 
ourselves  experience  is  a  matter  only  of  warranted  inference," 
he  is  stating  the  question  with  philosophical  accuracy,  which 
is  more  than  is  needful  in  a  discussion  as  to  the  amount  of 
scientific  probability.  Whether  or  not  sensations  or  impressions, 
being  "  associated  with  certain  subjective  phases  answering  to 
what  we  call  states  of  consciousness,"  arise  only  "  at  a  certain 
stage  in  the  complication  of  the  nervous  actions  of  the  lower 
organisms,"  when  the  "  ingoing  molecular  movements  traverse 
nerve  fibres,  and  thence  diffuse  themselves  among  related 
groups  of  nerve -cells,"  as  the  author  thinks,  or  whether,  as  we 
think,  there  is  an  uninterrupted  downward  chain  from  man  to 
the  amoeba,  in  which  states  of  consciousness,  gradually  receding 
from  the  highest  mind  to  the  dimmest  differentiation  between 
self  and  not-self,  is  a  question  only  of  more  or  less  legitimate 
inference  and  probability.  The  hypothesis  of  continuity,  how- 
ever, does  seem  more  in  accordance  with  the  ways  of  nature  and 
the  facts  of  the  case  than  of  discontinuity,  which  seems  to 
require  that  "  the  quick  succession  of  changes  in  a  ganglion, 
implying  as  it  does  perpetual  experiences  of  differences  and 
likenesses,  constitutes  the  raw  material  of  consciousness." 
We  must  pass  by  the  excellent  anatomical  chapters  on  the 
structure  of  the  nervous  systems  and  the  brains  of  the  different 
classes  of  animals,  to  arrive  at  the  important  chapter  on  the 
Scope  of  Mind.  We  may  very  well  omit  as  superfluous  in  these 
pages  any  notice  of  the  author's  well-put  objections  to  the 
custom  of  speaking  of  mind  as  "  an  actual  independent 
existence,"  or  even  as  "  a  definite  self-existing  principle." 
Mind  is  not  this  or  that,  but  according  to  John  Stuart  Mill, 
"  what  consciousness  directly  reveals,  together  with  what  can 
legitimately  be  inferred  from  its  revelations,  compose  by 
universal  admission  all  that  we  know  of  mind,  or  indeed  of  any 


220  CRITICAL   DIGESTS  AND 

other  thing."     And  this  passage  from  the  great  logician  seems 
to  supply  the  author  with  a  satisfactory  account  of  what  mind 
is,  subject,  as  we  shall  see,   to   certain  extensions  which   he 
himself  proposes ;  and  he  follows  up  the  curious  distinction  he 
makes  between  the  direct  revelations  of  consciousness  and  the 
inferences  we  draw  from  them,  with  the  reflection  that  it  would 
be  an  absurdity  to  rest  content  with  the  conclusion,  that  we  must 
lean  implicitly  and  conclusively  upon  these  direct  revelations 
of  consciousness.     But  the  author  does  not  inform  us  where 
inferences  exist  if  not  in  the  consciousness,  unless  he  intends 
to   include   them   among   those   "  mental   phenomena "    with 
which  he  contrasts  "  any  other  natural  phenomena,"  because 
f*  all  other  phenomena  can  only  be  known  in  terms  of  mind." 
We  do  not  know  that  this  application  of  the  term  phenomena 
is  quite  new,  but  it  certainly  is  not  quite  accurate,  for  how  can 
a  subjective  state  by  any  possibility  be  an  appearance  ?     "  The 
imaginative  embodiment  of  these  subjective  states  into  a  non- 
corporeal  or  spiritual  Ego,  is  not  altogether  (more)  surprising." 
But  our  author  here  again  permits  himself  to  contemplate,  and 
indeed  to  be  a  little  scared  by  the  supposed  consequences  of 
the  truth  he  is  seeking.     "  If  we  were  to  lean  implicitly  and 
exclusively  upon  these  direct  revelations  of  consciousness,  we 
must,   as   the   history   of   philosophy   has   shown,   inevitably 
commit  ourselves  to  a  system  of  universal  scepticism,  needing, 
as  Hume  proclaimed,  a  rejection  of  all  grounds  of  certainty 
for  our  belief  in  an  external  world,  in  body,  and,  indeed,  in 
mind,  as  an  entity — leaving  to  each  one  of  us  a  mere  fleeting 
series  of  conscious  states  as  representatives  of  the  totality  of 
existence.     The  absurdity  of  resting  content  with  such  a  con- 
clusion has  been  commonly  recognized  both  by  philosophers  and 
mankind  in  general.     In  fact  we  use   our   consciousness  to 
enable  us,  in  imagination  at  least,  to  transcend  these  direct 
revelations  of  consciousness.     They  are  by  each  one  of  us  in- 
variably supplemented  and  modified,  where  necessary,  by  what 
we  deem  to  be   legitimate   inferences.      Our  actual   present 
knowledge  is  made  up  of  a  closely  interwoven,  potential,  but 
intelligible  fabric  derived   from   actually   existent,   from   re- 
membered, described,  or  inferred  conscious  states  or  relations 
between   them,   together  with   inextricably   intermixed,    and 


NOTICES  OF  BOOKS.  221 

more  or  less  legitimate  inferences  therefrom."  Thus  we  have 
"  inferred  Conscious  States  "  and  "  legitimate  inferences  there- 
from "  which  are  not  Conscious  States,  in  order  that  we  may  not 
be  too  sceptical,  and  reject  grounds  of  certainty,  and  we  so,  in 
imagination  at  least,  transcend  the  revelations  of  Consciousness. 
Surely  also  "  endless  confusion  may  thus  be  produced  without 
commensurate  gain ;"  and  surely  in  our  search  for  knowledge  as 
to  the  nature  of  mind,  the  bogie  of  scepticism  regarding  the 
existence  of  body  need  not  scare  us,  as  it  certainly  will  not 
prevent  us  from  eating  our  dinner. 

But  we  shall  never  get  to  the  end  of  our  task  if  we  notice  all 
the  author's  opinions,  which  are  suggestive,  and  which  seem  to 
call  for  examination  if  not  criticism,  that  we  may  see  in  what 
sense  or  to  what  extent  we  may  accept  them ;  for  this  work  is 
far  removed  from  the  trite  methods  of  those  imitative  minds 
which  conceal  a  rickety  knowledge  of  physiology  with  a  poor 
veneer  of  mental  science.  No  doubt  it  is  very  difficult  to 
amalgamate  physiology  and  psychology,  or  to  bring  into 
unison  what  our  author  calls  the  subjective  phenomena  and 
the  objective  phenomena  of  thought,  and  the  difficulty  is 
increased  by  the  fact  that  the  popular  if  not  also  the  scientific 
terminology  of  the  matters  in  question  is  mostly  inherited  from 
times  antecedent  to  scientific  inquiry.  And  this  leads  us  to 
remark  that  however  we  may  be  inclined  to  concede  that 
"  the  notion  that  Brain  is  the  exclusive  organ  of  Mind  can  no 
longer  be  entertained,"  and  however  we  may  sympathize  with 
the  author  in  feeling  the  difficulty  which  arises  from  excluding 
unconscious  states  leading  to  or  linked  with  conscious  states  from 
the  term  Mind,  still  we  cannot  think  that  "  this  is  no  question 
of  choice,  but  one  of  absolute  necessity.  The  meaning  of  the 
word  Mind  must  be  very  considerably  enlarged,  so  as  to  enable 
us  to  comprise  under  its  new  and  more  ample  signification  the 
results  of  all  the  nerve  actions,  other  than  those  of  outgoing 
currents."  On  the  contrary  we  think  that  something  else  may 
be  done,  and  certainly  must  be  done,  in  the  gradual  formation  of  a 
new  terminology  more  consistent  with  the  development  of  neuro- 
logical science  ;  and  perchance  in  this  manner,  even  the  present 
generation  may  escape  from  being  called  upon  "  to  bear  the  dis- 
comfort and  inconvenience  arising  from  an  altered  meaning  of 


222  CRITICAL    DIGESTS  AND 

the  term  Mind  " — a  duty  of  sufferance  which  the  present  gene- 
ration would  probably  repudiate.  In  this  manner  those  who  do 
wish  to  think  and  to  communicate  their  thoughts  accurately 
would  gradually  provide  themselves  with  a  verbal  armament  as 
suitable  to  their  purpose  as  their  knowledge  would  enable  them 
to  fabricate.  And  who  knows  what  changes  in  scientific  terms 
may  be  found  needful,  while  leaving  the  old  landmarks  of  lan- 
guage where  they  are  ?  Nerve  centres,  discharges,  currents,  re- 
flections, inhibitions,  &c,  are  they  not  all  terms  based  upon 
hypotheses  more  or  less  probable  but  as  yet  unproved — all  of 
them  terms  which  new  knowledge  of  neuration  may  at  any  time 
relegate  to  the  limbo  where  phlogiston,  humidum  radicale,  and 
other  old  verbal  implements  which  rust  in  disuse  and  neglect  ? 

The  lucid  chapter  on  Sensation,  Idealism,  and  Perception 
concludes  with  a  pregnant  paragraph  on  "  the  possibilities  of 
intellectual  affection  and  action  bequeathed  to  an  organism  in 
the  already  elaborated  nervous  system  which  it  inherits. 
Within  this  nervous  system  lie  latent  the  creature's  forms  of 
Intuition  or  forms  of  Thought,  which  need  only  the  coming  of 
appropriate  stimuli  to  raise  them  into  harmonious  action.  It 
is  the  fact  of  the  previous  orderly  organization  of  the  structural 
correlatives  of  mental  processes,  which  causes  some  degree  of 
those  modes  of  mental  affection,  known  to  us  as  Feeling,  In- 
tellectual Action,  Emotion,  and  Volition,  to  be  engendered 
even  in  the  young  untaught  organism,  in  response  to  suitable 
stimuli." 

This  explanation  of  what  may  be  called  the  mental  Instincts, 
the  cause  of  untrained  and  untaught  cerebral  action  in  the 
young,  is  surely  also  the  largest  part  of  the  answer  to  the 
question  of  those  neurations  in  adult  lower  animals  which  are 
more  commonly  known  as  Instincts.  This,  indeed,  is  admitted 
in  the  conclusion  of  the  interesting  chapter  on  Instinct,  its 
Nature  and  Origin,  in  which  the  author  says  :  "  There  can 
be  no  doubt  that  if  our  means  of  knowledge  were  greater  than 
it  is,  we  should  be  able  to  explain  these  and  all  other  Instincts 
by  reference  to  the  doctrines  of  inherited  acquisition,  and 
natural  selection,  either  singly  or  in  combination."  It  seems 
to  us,  however,  somewhat  unnecessary  to  eliminate  these  two 
doctrines  out  of  one  process;  for  survival  of  the  fittest  can 


NOTICES   OF   BOOKS.  223 

only  become  influential  through  long-continued  inheritance. 
We  must  pass  by  the  excellent  chapters  on  the  Brains  of  the 
Quadrumana,  the  Mental  Powers  of  the  Higher  Brutes,  the 
Configuration,  Structure,  Function,  Kelations,  &c,  of  the 
Human  Brain,  that  we  may  glance  at  the  chapter  From 
Brute  to  Human  Intelligence.  In  this  linking  chapter  the 
author  very  fairly  traces  the  influence  of  the  possession  of 
articulate  speech,  "  an  endowment  which,  when  once  started, 
— whether  by  some  hidden  and  unknown  process  of  natural 
development,  or  as  a  still  more  occult  God-sent  gift  to  man — 
was  by  its  very  nature  almost  certain  to  have  led  its  possessors 
along  an  upward  path  of  cerebral  development."  Is  there  not 
somewhat  of  a  circle,  or  at  least  an  eddy,  in  the  current  of 
this  argument  ?  Speech  developes  the  brain  ;  but  does  not  the 
possession  of  a  large  brain  develope  speech  ?  As  the  author 
mentions,  the  men  of  the  Post-Tertiary  Drift  lived  for  untold 
ages  in  a  state  of  extreme  simplicity.  It  is  doubtful  to  what 
extent  they  were  social  or  solitary  ;  and  we  have  every  reason 
to  believe  that  their  language,  if  they  had  any,  was  most 
rudimentary.  Of  course,  social  habits  once  attained  and  lan- 
guage acquired,  the  progress  from  hieroglyphics  to  writing 
and  printing  and  stenography  and  telegraphy  must  have  run 
parallel  to  a  progress  from  simple  concepts  not  unlike  the  visual 
images  of  brutes,  through  conceptions  more  and  more  general 
and  abstract  and  complicated,  up  to  the  highest  development  of 
man's  intelligence.  The  well-considered  digest  of  our  know- 
ledge on  the  Functional  Relations  of  the  Principal  Parts  of 
the  Brain  has  a  chapter  separated  from  that  which  clearly 
belongs  to  the  subject,  namely,  Phrenology,  Old  and  New. 
In  considering  this  latter  division  of  brain-function,  the  author 
does  well  to  remind  us  that  "  only  within  the  last  century  has 
the  great  bulk  of  our  present  knowledge  with  regard  to  it  [the 
structure  and  functions  of  the  brain]  gradually  taken  shape 
from  amidst  the  clouds  of  error  with  which  the  opinions  of 
the  ancients  and  the  mere  speculations  of  the  anatomists  of 
later  centuries  had  enshrouded  it ;"  and  he  gives  an  excellent 
resume  of  these  opinions,  culled  and  condensed,  as  he  says,  for 
the  most  part  from  the  writings  of  Prochaska — that  neurological 
mine  which  has  too  often  been  worked  without  acknowledg- 


224  CRITICAL  DIGESTS   AND 

ment.  The  old  system  of  Phrenology  of  Gall  and  Spurzheim, 
founded,  as  the  author  says,  upon  a  crude  psychological 
analysis,  well  capped  by  a  very  simple  mode  of  hap-hazard 
and  tentative  observation,  and  fallacious  in  almost  every 
respect,  was  very  different  to  the  new  method  of  experi- 
mentation by  which  questions  of  the  localization  of  cerebral 
formation  are  carefully  put  to  nature.  The  yea  or  nay  of  the 
general  question  of  localization  of  function  has  underlying  it 
the  secondary  one  whether  mental  faculties  are  dependent 
upon  separate  areas  of  brain-substance,  or  whether  cells  and 
fibres,  so  far  as  position  is  concerned,  are  interblended  with 
others  having  different  functions.  "Have  we  to  do  with 
topographically  separate  areas  of  brain-tissue,  or  merely  with 
distinct  cell  and  fibre  mechanisms,  existing  in  a  more  or  less 
diffuse  and  mutually  interblended  manner  ?  " 

The  search  for  perceptive  centres,  taken  up  by  Ferrier  in 
"  a  thoroughly  systematic  manner,"  and  pursued  by  him  "  with 
characteristic  energy,"  led  to  results  which  "  deserve  to  be 
most  carefully  studied."  The  reader  is  referred  to  the  original 
for  full  details  of  these  experiments,  "  made  with  much  skill 
and  judgment ;"  the  author's  opinion  respecting  them  being, 
that  "  although  Ferrier's  determinations  of  the  sites  which  are 
of  most  importance  for  each  sense  require  more  confirmation 
by  other  workers  than  they  have  yet  received,  before  they  can 
finally  be  accepted  as  correct,  the  discrimination  and  ability 
with  which  his  experiments  have  been  conducted  should 
ensure  for  them  that  careful  and  thorough  testing  which  their 
importance  deserves."  We  have  only  space  left  to  indicate  the 
great  interest  and  importance  of  the  concluding  chapters  on 
Speaking,  Beading,  and  Writing,  as  mental  and  physiological 
processes  ;  on  the  Cerebral  Eelations  of  Speech  and  Thought ; 
and  on  Problems  in  regard  to  Localization  of  Higher  Cerebral 
Functions ;  and  to  take  leave  for  the  present  of  this  most 
valuable  addition  to  the  popular  series  of  science  treatises, 
of  which  it  is  the  youngest  recruit,  with  the  expression  of 
our  own  opinion  that  the  diverse,  complicated,  and  profound 
problems  of  psychology  and  neurology  with  which  it  is  engaged 
have  never  before  been  so  fully,  ably,  and  lucidly  presented 
to  the  general  reader. 

John  Charles  Bucknill. 


NOTICES  OF   BOOKS.  225 

Mind  in  the  Lower  Animals,  in  Health  and  Disease.  By  W. 
Lauder  Lindsay,  M.D.  2  vols.  C.  Kegan  Paul  &  Co., 
London,  1879. 

This  is  a  work  of  formidable  dimensions,  consisting  of  two 
volumes  of  more  than  500  pages  each,  the  first  being  devoted 
to  the  mind  of  the  lower  animals  in  health,  the  second  in 
disease.  The  author  tells  us  that  he  had  at  first  intended  to 
produce  a  book  of  much  less  size,  but  that  on  attempting  it  he 
found  the  materials  so  swollen  that  he  could  not  compress  it 
within  its  present  limits,  though  we  confess  to  the  opinion  that 
some  diminution  of  its  contents  would  enhance  the  value  of 
the  whole. 

In  substance  it  is  composed  of  a  vast  quantity  of  notes, 
slowly  accumulated  by  the  author,  gleaned  from  a  wide  area 
of  experience  covered  by  travel  and  reading,  while  prompted 
by  the  motives  of  a  "  physician-naturalist,"  as  he  styles 
himself,  in  the  former  capacity  being  specially  occupied  with 
mental  disease ;  but  neither  does  there  appear  to  have  been 
enough  partiality  in  the  collection,  nor  has  the  matter  received 
sufficient  elaboration  in  passing  through  the  author's  mind 
to  have  exchanged  much  of  its  crude  note-like  form,  for  the 
more  compact  and  comely  presentment  of  ingenious  theory, 
although  it  has  been  somewhat  arranged  and  adorned  with 
comments. 

Dr.  Lindsay  says  (Introd.  p.  xiv.)  he  "attempts  to  outline 
the  subject  of  Mind  in  the  Lower  Animals,  to  illustrate  their 
possession  of  the  higher  mental  faculties  as  they  occur  in  man, 
of  reason  as  distinguished  from  mere  instinct."  He  is  modest 
in  his  claims,  and  intends  only  a  popular  treatise,  therefore  he 
must  not  be  regarded  too  harshly. 

There  is  too  little  coherence  in  the  book  to  make  it  an  easy 
task  to  criticise  it  as  a  whole,  and  the  bulk  is  too  great  to 
allow  detailed  examination.  Yet  it  is  soon  visible,  on  perusing 
the  book,  that  the  author's  aim  is  to  exalt  animals  at  the 
expense  of  man,  in  opposition  to  the  depreciation  with  which, 
by  what  the  author  considers  human  prejudice,  they  are 
generally  received ;  though,  of  course,  he  does  not  quarrel 
with  the  vast  superiority  of  man  in  his  most  complete  develop- 

VOL.    III.  Q 


226  CRITICAL   DIGESTS  AND 

ment,  he  selects  the  more  backward  types  of  the  human  race 
— e.g.  savages,  criminals  (whose  brutal  habits  afford  the 
opportunity  for  sarcasm  at  our  so-called  civilisation),  idiots, 
lunatics,  &c,  for  description — to  compare  with  the  best  ex- 
amples of  the  lower  animals.  Notwithstanding  the  care  with 
which  this  comparison  is  in  many  respects  pursued — and  no 
one  can  doubt  the  honesty  of  the  author,  though,  perhaps,  his 
enthusiasm  may  be  a  little  mis-directed — there  seems  a  good 
deal  of  the  art  of  the  advocate  in  place  of  the  strict  im- 
partiality of  an  inquirer  after  truth ;  there  is  the  truth,  but  not 
the  whole  truth.  The  method  and  plan  employed  are,  un- 
fortunately, by  no  means  innocent  of  logical  faults ;  one  of 
the  most  serious  being  too  common  in  the  scientific  exami- 
nation of  a  system — such  as  the  mind — of  instituting  a 
comparison  piecemeal,  of  each  pair  of  elements  in  isolation, 
apart  from  their  relation  to  the  rest  of  the  system.  Thus  the 
structure  formed  by  the  parts  in  combination,  which  is  really 
almost  the  sole  object  of  search,  eludes  observation,  just  as  the 
soul  has  evaded  the  anatomist's  knife;  so  that  although  it 
might  be  proved  that  in  certain  single  characteristics  or 
aspects  the  excellence  might  belong  to  the  member  of  the 
more  humble  class,  yet  it  by  no  means  follows  that  the  total 
mind  of  the  animal  in  question  will  equally  bear  the  palm. 
Scarcely  any  attention  is  paid  to  the  important  fact  that  man 
possesses  a  larger  number  of  highly-varied  and  nearly  always 
more  highly-developed  faculties,  and  a  versatility  in  their 
application  that  is  peculiar  to  himself.  Further,  the  reader 
feels  oppressed  by  a  strained  analogy  throughout  the  book — 
what  is  outwardly  similar  being  regarded  as  essentially 
identical — perhaps  to  meet  preconceived  views  as  to  the  re- 
semblance, the  chief  form  this  takes  being  the  fallacy  of 
anthropomorphism,  animals  being  credited  with  human 
motives,  on  which  subject  he  remarks  (Vol.  I.  chap,  xviii.)  that 
interpretation  of  motives  is  very  difficult,  even  in  our  fellow- 
men  ;  and  he  assumes  that  the  "  attribution  of  human  motives 
is  both  legitimate  and  necessary  "  (p.  339).  As  an  example 
of  this  we  would  refer  to  the  case  (Vol.  II.  p.  301)  of  sporting 
dogs  being  described  as  filled  with  disgust  and  contempt,  and 
consequently  deserting  their  master,because  of  his  incompetence 


NOTICES   OF   BOOKS.  227 

and  want  of  skill  as  a  sportsman  ;  but  is  it  not  much  more  likely 
that  their  desertion  was  due  to  disappointment  at  failing  to 
obtain  the  pleasures  of  a  successful  chase  ?  If  all  such  interpre- 
tations were  admissible,  one  would  be  almost  persuaded  of  the 
possible  truth  of  iEsop's  fables !  Another  frequently-repeated 
variety  of  the  same  error  is  the  confusion  of  similarities  of 
analogy  with  those  of  homology,  as  well  as  different  stages  in  the 
development  of  a  function  with  one  another,  for  in  psychology, 
not  only  the  quality  of  a  particular  sentiment,  but  also  the 
range  of  its  application — i.e.  its  intellectual  equivalent — must 
be  taken  into  consideration  in  estimating  its  real  character. 
Again,  he  is  apt  to  confound  mere  imitativeness  with  spon- 
taneous efforts  at  construction,  thus  assigning  too  much  credit 
to  the  imitator;  also  he  does  not  always  appear  to  attach 
sufficient  importance  to  the  power  to  adapt  means  to  ends,  or 
to  distinguish  accurately  between  the  qualities  learnt  by 
natural  experience  and  those  taught  by  man. 

The  work  cannot  claim  pretensions  to  be  a  system  of  com- 
parative psychology,  for  there  is  not  much  philosophical 
comprehension  of  a  standard  of  comparison,  or  a  thorough 
scientific  analysis  of  the  mind  into  its  several  faculties,  to  be 
traced  in  their  grades  of  development  through  the  several 
classes  of  the  animal  kingdom. 

The  author  discards — perhaps  with  good  reason — any  classi- 
fication of  mental  faculties  at  present  in  vogue,  but  acknow- 
ledges his  inability  to  frame  a  better. 

Instead  of  this,  groups  of  mental  phenomena  are  taken 
somewhat  promiscuously,  according  to  their  outwardly  pro- 
minent features,  to  head  the  different  sections  and  chapters 
of  the  book;  and  these  groups  are  sub-divided  arbitrarily, 
like  a  catalogue,  into  various  lists  of  minor  qualities,  arranged, 
in  rather  monotonous  series,  too  much  like  the  objects  collected 
in  an  ordinary  museum.  This  arbitrary  arrangement  of  so 
large  a  quantity  of  facts  is  certainly  one  of  the  chief  obstacles 
to  appreciation  of  the  author's  work,  for  it  renders  the 
book  somewhat  dreary  to  read,  though  perhaps  it  may  be 
in  accordance  with  the  Baconian  rules  for  conducting  the 
investigation  of  nature.  It  might  also  be  objected  with  some 
force   that  there   is  as  yet  insufficient  material  to  pursue  a 

Q  2 


228  CRITICAL   DIGESTS   AND 

satisfactory  comparison  between  animal  and  human  minds. 
The  resemblance,  here  performed  somewhat  cumbrously,  is  in 
tone  much  like  the  masterly  account  given  on  a  smaller  scale, 
with  much  more  justice  and  eloquence,  in  Darwin's  '  Descent 
of  Man.'  To  have  drawn  an  adequate  picture  with  predomi- 
nance of  the  distinctions  above  the  general  agreement  would 
indeed  have  been  invaluable,  but,  as  the  author  regrets, 
almost  impracticable.  We  think  that  failure  thoroughly  to 
appreciate  the  points  of  difference  has  led  him  to  exaggerate 
the  fundamental  identity. 

In  introducing  the  work  to  his  readers,  the  author  describes 
the  method  he  has  endeavoured  to  employ  in  its  preparation, 
laying  down  at  length  what  he  considers  to  be  the  best  rules 
for  conducting  scientific  research ;  giving  due  notice  of  the 
chief  fallacies  to  be  avoided ;  so  that  we  presume  he  assails 
his  task,  thus  guided  and  protected,  with  no  want  of  self- 
confidence.  He  says  he  aims  only  at  laying  down  facts,  but 
is  careful  to  attest  them  by  reference  to  and  examination  of 
the  authorities  whence  he  draws  them.  We  do  not  feel  alto- 
gether satisfied  with  either  of  these  attempts,  for  such  a  huge 
record  of  facts  is  greatly  diminished  in  value  by  being  imper- 
fectly digested ;  and  certainly  many  of  them  demand  a  heavy 
tax  on  our  credulity  to  obtain  acceptance,  e.g.  that  sperm 
whales  communicate  with  each  other  at  the  distance  of  six  or 
seven  miles !  (Vol.  I.  p.  420)  although  the  author  declares  he 
has  been  at  pains  to  verify  all  his  borrowed  information.  We 
suppose  that  it  must  be  from  a  slip  of  which  the  author  was 
unaware  that  we  find  the  absurdity  (Vol.  I.  p.  420)  that,  among 
other  animals,  the  guinea-pig  uses  its  tail  as  a  respirator,  and 
to  maintain  its  warmth !  The  chief  sources  of  the  author's 
information  are  the  works  of  J.  G.  Wood,  Houzeau,  and 
Pierquin,  the  Animal  World,  and  current  newspapers,  besides 
original  observations,  for  which  his  extensive  travels  have 
given  him  the  opportunity. 

In  spite  of  the  abundance  of  matter,  we  are  inclined  to 
believe  that  more  profound  studies  of  fewer  cases,  and  the 
detailed  discussion  of  intricate,  knotty,  and  interesting  pro- 
blems, would  have  been  more  profitable  than  the  mere  deposi- 
tion and  enumeration  of  the  mass  of  facts  which  overcrowd 


NOTICES   OF   BOOKS.  229 

these  volumes ;  it  must  remain  a  work  for  consultation  rather 
than  for  ordinary  reading,  though  not  exhaustive  enough  to 
constitute  a  standard  work  of  reference ;  for  we  believe  that 
contributions  to  science — at  least  in  the  inexact  department  of 
natural  history — lose  much  of  their  worth  by  extreme  dryness  of 
statement,  just  as  jewels  are  less  esteemed  when  reduced  to 
powder  instead  of  remaining  of  larger  size,  and  being  duly  cut 
and  advantageously  set.  However,  we  will  gratefully  offer  at 
least  one  fragment  of  commendation — to  the  attempt  to  give 
an  account  of  the  phenomena  of  mind  without  constantly 
referring  to  unmeaning  nerve-cells,  &c,  for  explanation.  The 
first  section  consists  of  a  brief  outline  of  comparative  psycho- 
logy, showing  the  increasing  mental  complexity  in  the  ascent 
through  the  invertebrate  and  vertebrate  classes,  although  the 
psychological  and  zoological  scales  do  not  coincide.  A  chapter 
is  given  to  show  how  incorrect  is  the  character  given  to  some 
species  of  animals  by  popular  estimation ;  usually  worse  than 
they  deserve,  though  sometimes  they  make  more  blunders  than 
are  expected  of  them.  Chap.  ix.  contains  a  list  of  alleged 
psychical  differences  between  man  and  animals ;  but  they  are 
all  held  to  be  neither  invariably  present  in  man,  nor  always 
absent  from  animals.  The  popular  belief  in  a  sharp  demar- 
cation between  instinct  and  reason  is  strongly  contested ;  every 
animal  is  further  said  to  possess  a  distinct  individuality.  Some 
curious  familiar  subjects  are  dealt  with  in  chap,  xiii.,  under 
the  head  of  "  Unsolved  Problems,"  including  migrations,  &c. ; 
but  not  a  very  great  amount  of  the  light  of  reason  is  brought 
to  bear  upon  it.  Then  begins  the  detailed  study  of  the  mind  in 
its  normal  manifestations :  the  first  subject  treated  of  being  the 
moral  sense,  and  in  order  to  draw  as  near  as  possible  a  com- 
parison between  its  developments  in  man  and  animals,  its 
presence  in  some  lower  specimens  of  humanity  is  at  first  con- 
sidered ;  it  is  declared  to  be  occasionally  absent,  perverted  in 
disease,  and  to  decay  in  old  age.  A  list  is  given  of  a  large 
number  of  features  of  the  moral  sense  in  savages,  &c,  of  many 
immoral  characters  present  instead.  From  man,  the  step  is 
taken  to  lower  animals ;  but  it  would  have  been  well  to  stay 
to  ascertain  how  far  the  terms  "  right "  and  "  wrong  "  are  at 
all  applicable  to  animals,  seeing  that  the  courses  of  action 


230  CRITICAL   DIGESTS  AND 

among  which  they  have  to  choose  are  less  numerous  and  less 
embarrassing  than  in  the  case  of  man,  and  especially  as  the 
social  conditions  of  the  latter  give  quite  a  novel  direction  to 
his  life.     The  author  admits  that  "  what  is  popularly  spoken 
of  as  a  sense  of  right  and  wrong,  of  legality  or  illegality,  in 
the  lower  animals,  may,  or  will,  if  strictly  analysed,  be  reduced 
to  a  distinction  between  what  is  forbidden  and  what  is  permitted 
by  man,  who  is  recognised  as  a  sufficient  lawgiver  and  adminis- 
trator— what  will  bring  punishment  on  the  one  hand  and  reward 
on  the  other"  (p.  181).     "But,"  he  adds,  "this  is  just  the 
kind  of  feeling  that  exists  in  the  savage,  the  civilised  child, 
the  lunatic,  or  idiot."     But  he  certainly  does  not  show  that  it 
becomes  so  large  a  portion  of  the  mind,  its  pursuit  so  inde- 
pendent, in  any  animal  as  in  man ;  he  holds  that  there  is  no 
reality  in  the  objection  that  what  are  apparently  moral  acts 
are  not  really  so.     As  corroborative  of  his  views  of  the  moral 
responsibility  of  animals,  he   mentions  that   their  acts  were 
formerly  so  regarded  in  courts  of  law ;  and  in  extenuation  of 
their  would-be  faults,  he  holds  that  many  of  them  are  due  to 
man's  ill-training.     The  same  subject  is   also  treated  of  in 
other  parts  of  the  work,  viz.  chap.  xxii.  on  Law  and  Punish- 
ment, where  it  is  stated  that  some  animals  have  rules  laid 
down  by  authority  and  custom — a  law  of  right  as  well  as  a 
law  of  might ;  they  have  rights  in  property  and  rank.     Some 
birds  have  apparent  judicial  proceedings  ;  and  there  are  exhi- 
bited a  variety  of  punishments.     The  obverse  of  the  same 
question  is  handled  in  Vol.  II.  chap,  xi.,  on  Crime  and  Crimi- 
nality, showing  that  they  may  be  guilty  of  offences  against  man's 
or  their  own  laws ;   their  faults  being  theft  and  destructive- 
ness,  including  murder  and  mutilation,  and  they  are  conscious 
of  their  criminality.    In  a  chapter  on  "  Sensitiveness  "  is  shown 
their  keen  susceptibility  to  the  opinions  of  their  fellows,  &c. 
The  ethics  of  vivisection  are  not  discussed.     Next  comes  an 
account  of  the  religious  feeling — first  in  man,  in  whom  it  is 
shown  that  there  is  sometimes  no   notion   of  any   Supreme 
Being ;  in  savages  there  is  fetish  and  ancestor  worship,  and 
hero-worship  even  in  civilised  man.     Then  the  religious  feel- 
ing is  stated  to  exist  in  many  animals;    but  the  proofs  of 
exalted  feeling  seem  scarcely  convincing.    That  many  domestic 


NOTICES  OF   BOOKS.  231 

animals  look  on  man  as  a  god  is  very  likely  true ;  yet,  in  com- 
paring them  with  men,  it  must  be  recollected  how  much  more 
easy  it  is  for  them  to  form  such  an  idea,  having  the  object  of 
reverence  within  reach  of  their  perception.  The  analogy  is 
surely  carried  much  too  far  in  ascribing  attendance  at  church 
by  dogs  to  gratification  of  a  religious  sentiment !  and  piety 
to  parrots  for  repeating  prayers  ! 

Next,  the  capacity  for  education  is  discussed,  and  Ch.  X. 
contains  some  interesting  information  of  the  training  required 
by  the  young  of  many  species  to  develope  some  of  even  the 
strongest  instinctive  aptitudes. 

Next  the  distribution  of  language  is  considered.  We  cannot 
understand  on  what  grounds  it  can  be  held  that  "  animal 
language  is  more  comprehensive  than,  and  quite  as  eloquent 
as,  man's."  Houzeau's  remark  also  is  quoted  with  approbation, 
that  the  language  of  certain  savages  is  inferior  to  that  of 
various  animals.  The  author  expresses  an  opinion  that  a  pro- 
fessorship of  comparative  language  should  exist  in  all  universi- 
ties, and  due  attention  given  to  all  forms  of  expression  common 
to  other  animals  with  man.  Several  pages  are  occupied  with 
a  long  alphabetical  list  of  the  significations  of  animal  vocal 
sounds ;  and  it  is  noteworthy  that  all  are  names  of  states  of 
feeling,  thus  suggestive  of  the  interjectional  origin  of  language, 
and  of  the  degree  to  which  the  mind  must  have  developed 
before  articulate  speech  arose.  Laughter  is  shown  to  be 
neither  universal  in,  nor  peculiar  to,  man;  weeping  is  an 
expression  of  grief  common  to  many  animals. 

The  rest  of  Vol.  I.  is  devoted  to  more  special  phenomena ; 
under  the  heading  of  "  Adaptiveness,"  it  is  shown  of  what 
variation  the  powers  of  animals  admit ;  what  use  they  make  of 
the  members  of  their  own  bodies,  of  natural  objects,  and  man's 
instruments;  that  they  occasionally  delight  to  clothe  them- 
selves, prepare  food,  and  provide  themselves  with  shelter  ;  also 
that  they  combine  to  form  societies,  with  one  or  other  form  of 
government ;  that  they  often  show  considerable  acquaintance 
with  numbers  and  skill  in  calculation,  including  the  exact 
appreciation  of  time.  Their  habits  of  courtship  and  marriage 
are  described ;  and  numerous  illustrations  are  given  of  the 
satisfaction  of  the  maternal  instinct  by  foster  parentage. 


232  CRITICAL   DIGESTS   AND 

Vol.  II.  is  devoted  to  morbid  phenomena,  regarded  by  the 
author  as  of  chief  importance.  As  before,  the  pathology  of 
animals  is  arrived  at  through  that  of  man.  The  use  of  a 
knowledge  of  the  subject,  besides  its  scientific  interest,  is  said 
to  be  for  its  great  practical  benefit,  for  the  author  believes  that 
the  efficiency  of  animals  as  servants  of  man  depends  very 
largely  on  their  mental  soundness,  especially  the  training  and 
moral  care  they  receive;  he  also  holds  that  bodily  states 
depend  on  mental  condition  in  other  ways  that  will  scarcely 
be  believed  by  many,  e.g.,  that  contagious  rabies  is  producible 
in  the  dog  by  exciting  passions !  and  that  the  milk,  blood  and 
flesh  of  animals  may  be  rendered  poisonous  by  mere  protracted 
suffering. 

A  likeness  is  drawn  between  the  symptoms  of  animal  and 
human  insanity,  the  general  course  and  a  number  of  leading 
appearances  being  shown  to  be  common  to  both,  e.g.,  idiocy, 
imbecility,  acute  and  chronic  mania,  with  monomania,  acute 
primary,  secondary  and  senile  dementia,  various  morbid  im- 
pulses, such  as  kleptomania,  erotomania,  dipsomania  (for  many 
animals  acquire  a  partiality  for  alcoholic  excess),  and  perversion 
of  the  natural  affections  being  often  well  marked.  No  mention 
is  made,  however,  of  epilepsy  or  general  paralysis.  But  in  this 
account  of  mental  arrangement,  mere  temporary  mental  dis- 
turbance is  too  much  mixed  up  with  genuine  insanity.  In  the 
matter  of  sleep  and  dreams,  there  seems  much  evidence  of 
exact  similarity  between  animals  and  man.  Suicide  is  declared 
to  be  as  common  and  as  various  in  its  mode  of  performance 
as  in  man!  Several  chapters  are  devoted  to  aetiology,  the 
attempt  being  made  to  show  that  the  causes  closely  correspond 
in  animals  and  man  ;  they  are  divided  into  physical  (including 
physiological  and  pathological)  processes,  moral,  and  mixed. 

The  final  section  of  the  book  is  occupied  with  practical 
conclusions,  consisting  of  directions  for  the  training  and  care 
of  domestic  animals;  but  we  cannot  see  that  many  of  these 
rules  are  deserving  of  such  deliberate  and  explicit  statement 
in  this  book  ;  or  even  that  their  formal  laying  down  will  lead 
to  much  practical  benefit. 

The  means  for  treating  animal  insanity  are  also  described ; 
but  without  the  mention  of  anything  suggestive  or  important. 


NOTICES  OF  BOOKS.  233 

The  book  concludes  with  an  appendix  of  a  full  bibliography, 
an  interminable  list  of  animals  referred  to,  and  a  long  analy- 
tical index. 

F.  L.  Benham,  M.B. 


Ves  Paralysies  dans  les  Maladies  Aigu'es.    By  Dr.  L.  Landouzy. 
Paris :  Bailliere  and  Co.     8vo.,  pp.  362. 

Under  the  name  of  paralysis  in  acute  disease  has  been 
collected  a  vast  mass  of  more  or  less  heterogeneous  material, 
which  the  author  of  the  present  volume  has  endeavoured  to 
sift  and  classify  as  much  as  possible.  Though  much  remains 
to  be  done  yet  before  we  can  hope  to  understand  thoroughly 
the  multifarious  phenomena  of  febrile  akinesiee,  we  welcome 
Dr.  Landouzy 's  work  as  one  likely  to  hasten  that  time,  were  it 
only  by  clearing  the  ground  of  much  ambiguity  and  many 
premature  theories. 

The  group  of  paralyses  under  consideration  is  purely  a 
clinical  one,  and  every  attempt  to  reduce  them  to  an  artificial 
unity  by  calling  them  paralyses  of  "  convalescence,"  or  of 
"  asthenia,"  or  reducing  them  to  the  "  diffuse,"  "  peripheric," 
"amyotrophic,"  "essential,"  "reflex,"  or  other  types,  must 
necessarily  fail.  The  present  volume  opens  with  some  general 
and  historical  considerations  of  much  interest ;  but  we  will  at 
once  plunge  in  medias  res  and  follow  the  author  in  the 
clinical  description  of  the  paralyses  occurring  in  various  acute 
diseases,  and  then  summarize  with  him  our  present  notions 
with  reference  to  their  pathogeny  and  pathology. 

Paralytic  symptoms  after  diphtheria  are  very  common,  and 
in  no  way  depend  upon  the  severity  or  locality  of  the  primary 
disease.  Paterson  ('  Medical  Times  and  Gazette,'  1866,  p.  608) 
describes  an  interesting  case,  in  which  diphtheritic  inoculation 
at  the  wrist  was  followed  by  paralysis  of  the  four  extremities. 
Curiously  enough,  the  palate  muscles  escaped.  Diphtheria 
is  more  frequently  followed  by  paralysis  in  adults  than  in 
children,  but  the  presence  of  albuminuria  does  not  seem  to 
have  any  causal  relation  to  the  evolution  of  this  symptom. 


234  CRITICAL   DIGESTS   AND 

The  first  muscles  to  lose  power  are  usually  those  of  the 
palate.  If  the  nervous  disturbance  spreads,  the  eyes  are 
affected  next,  then  the  legs  and  arms.  When  the  paralysis 
remains  localized,  it  usually  runs  a  short  and  favourable 
course  ;  but  if  it  becomes  generalized,  recovery  is  much  more 
protracted,  though  even  then  it  may  disappear  in  a  few  weeks. 
From  every  point  of  view,  diphtheritic  paralysis  is  charac- 
terised by  a  great  mobility  of  symptoms,  though  Trousseau 
has  certainly  exaggerated  this  fact.  The  symptoms  more 
particularly  characteristic  of  a  paretical  condition  of  the 
palate  are  a  nasal  twang,  difficulty  of  deglutition,  of  suction, 
of  blowing,  of  gargling.  The  pharynx  and  larynx  may  become 
involved  along  with  the  palate.  The  disturbances  referable  to 
vision  are  due  to  diminution  of  the  power  of  accommodation ; 
paralysis  of  the  muscles  of  the  globe  are  much  less  frequent. 

The  legs  are  more  commonly  affected  than  the  arms.  Hemi- 
plegia has  never  been  shown  to  follow  diphtheria.  There  are 
frequently  troubles  in  the  sensory  sphere,  paraesthesiae,  and 
anaesthesiae,  which  may  even  exist  without  loss  of  motor 
power.     Sometimes  there  is  ataxia. 

The  diaphragm  and  other  respiratory  muscles  are  occa- 
sionally involved,  as  Duchenne  so  well  showed.  Dr.  Landouzy 
gives  a  very  interesting  case  in  which  this  distinguished  phy- 
sician apparently  saved  the  patient's  life  on  several  occasions 
by  faradisation ;  and  other  cases  illustrating  the  implication  of 
the  pneumogastric  and  consequent  cardiac  syncope. 

Many  French  writers  follow  Gubler  in  describing  a  non- 
diphtheritic  anginal  paralysis.  But  our  author  thinks  it  more 
probable  that  the  confessedly  very  rare  cases  where  such  a 
paralysis  has  been  observed  were  really  diphtheritic.  The 
distinction  between  the  diphtheritic  and  "  herpetic  "  anginae 
is  sometimes  very  difficult  to  uphold,  and  the  course  of  the 
paralytical  symptoms  in  both  instances  is  precisely  the  same. 

The  paralyses  depending  on  typhoid  fever  are  so  various 
that  it  is  not  easy  to  summarise  their  symptomatology  and 
pathology.  Dr.  Landouzy  illustrates  them  copiously  with 
cases  which  we  can  only  recommend,  to  the  attention  of  our 
readers.  In  the  majority  paralysis  occurs  during  convalescence, 
and  appears  as  paraplegia  or  hemiplegia  (with  aphasia  some- 


NOTICES  OF  BOOKS,  235 

times,  especially  in  children),  and  is  only  temporary.  The 
bladder  is  very  often  affected.  Besides  these  disturbances, 
of  central  origin,  typhoid  fever  may  also  cause  neuritis  and 
myositis,  with  muscular  atrophy. 

Dr.  Landouzy  discusses  the  pathology  of  dysenteric  para- 
lysis, and  thinks  that,  in  the  absence  of  direct  proof  of  an 
ascending  neuritis,  the  clinical  evidence  points  rather  to  a 
primarily  myelitic  process.  On  the  other  hand,  the  local 
paralyses  (and  anaesthesias),  such  as  that  of  the  orbicularis 
palpebrarum  observed  in  the  early  stage  of  cholera,  would 
seem  to  be  rather  of  peripheric  origin. 

With  reference  to  intermittent  fever,  two  types  of  para- 
lyses must  be  distinguished.  The  first  is  characterised  by  a 
transitory  loss  of  power,  intimately  bound  up  with  the  febrile 
attack,  and  by  aphasia,  with  preservation  of  consciousness. 
The  second  is  the  "  hemiplegic  "  form  of  the  pernicious  fever 
of  authors.  It  is  distinguished  by  the  severer  nature  of  the 
symptoms,  which  are  less  readily  modified  by  quinine,  and 
persist  after  the  febrile  attack.  These  paralyses  are  probably 
of  cortical  origin,  and  have  been  explained  by  a  mere  con- 
gestive process;  but  it  is  possible  that  inelanaemia  is  not 
without  influence  on  their  production. 

In  connection  with  variola,  we  occasionally  find  a  para- 
plegia, or  rather  a  paraparesis,  and  a  number  of  akinesias, 
all  of  temporary  duration,  occurring  during  the  early  stage. 
During  convalescence  a  variety  of  nervous  symptoms  may  also 
supervene,  both  motor  and  sensory,  diffuse  or  localised,  some- 
times with  muscular  atrophy  or  ataxia.  The  latter  symptom  has 
been  lately  studied  by  Kahler  and  Pick  ('  Prager  Vierteljahr- 
schrift,'  1879).  Joffroy  found,  in  a  case  of  post-variolic  atrophy 
of  the  left  arm,  the  cord  apparently  healthy,  though  both  nerve 
and  muscles  showed  signs  of  advanced  degenerative  atrophy 
(<  Arch,  de  Physiologic,'  1879). 

Transitory  paraplegia  has  rarely  been  observed  as  a  sequel 
of  measles.  In  scarlatina,  early  paralysis  is  said  to  be  of 
grave  omen.  A  case  is  reported,  however  (*  Med.  Times,' 
1868),  where  a  child  recovered  from  a  generalised  paralysis, 
which  supervened  in  the  middle  of  the  disease.  The  patient, 
it  must  be  added,  was  of  neurotic  disposition  :  an  illustration 


236  CRITICAL   DIGESTS  AND 

of  the  general  proposition  that  fevers  often  seize  upon  the 
locus  minimse  resistentim  of  the  organism,  whence  the 
variety  observed  in  their  manifestations.  Dr.  Landouzy  thinks 
it  not  unlikely  that,  apart  from  actual  meningeal  growths, 
there  may  exist,  in  acute  tuberculosis,  a  neuritis  which  would 
explain  the  neuralgic  symptoms  met  with  in  the  disease. 
Sciatica  is  not  uncommon,  and  Eisenlohr  showed  it  to  depend, 
in  a  case  lately  published,  on  a  neuritis  of  the  sciatics. 

In  acute  rheumatism,  if  we  eliminate  apparent  paralyses 
and  those  due  to  embolism,  paralysis  due  to  a  direct  influence 
on  the  cord  or  nerves  is  rare,  and,  when  present,  fugitive  and 
mobile.  It  may  appear  early  in  the  disease  or  during  con- 
valescence. 

With  reference  to  the  hemiplegias  observed  in  pneumonia, 
Dr.  Landouzy  adopts  Lepine's  view,  who  explains  them  by 
some  circulatory  disturbance  of  the  brain.  They  most  fre- 
quently occur  in  old  people  with  atheromatous  arteries. 

The  author  discusses  the  question  of  "  reflex  "  paralyses  in 
relation  to  the  hemiplegias  observed  in  the  later  stages  of 
pleurisy.  Under  this  rather  unfortunate  name — reflex  applies 
to  action,  not  to  the  loss  of  action — we  include  none  but  the 
cases  where  either  an  autopsy  or  a  very  rapid  recovery  has 
shown  the  absence  of  any  serious  spinal  lesion.  In  pleurisy 
some  cases  of  hemiplegia  are  clearly  due  to  embolism,  whilst 
others  are  "  reflex  :"  that  is,  depend  upon  a  centripetal  irrita- 
tion, producing,  according  to  some,  an  ischaemia,  or,  according 
to  others,  a  functional  disturbance  of  the  motor  cells. 

Until  1862,  when  Charcot  and  Vulpian  published  the  first 
observation  of  the  neuritic  origin  of  a  paralysis  of  the  palate 
consecutive  to  diphtheria,  all  such  akinesia?  were  considered 
as  functional  or  asthenic.  From  that  day  records  of  or- 
ganic lesions  in  similar  cases  became  frequent,  and  in  1878 
Dejerine  published  his  conclusions  (see  '  Brain,'  Vol.  I.  p.  226), 
based  on  five  personal  observations.  Dr.  Landouzy  thinks 
that  the  conclusions  to  be  deduced  from  the  facts  actually 
before  us  are  that  there  is  a  primary  interference  with  the 
nutrition  of  the  spinal  cord,  more  particularly  of  its  large 
cells ;  and,  secondary  to  this,  neuritis  of  the  anterior  roots, 


NOTICES  OF   BOOKS.  237 

motor  nerves,  with  consequent  paralysis.  He  considers  the 
time  which  elapses  between  the  febrile  period  and  that  of  the 
paralytic  symptoms  as  one  of  incubation,  so  to  speak,  during 
which  the  necessary  impregnation  of  the  cord  by  the  poison 
gradually  takes  place. 

With  reference  to  small-pox,  the  observations  of  Westphal 
show  the  occurrence  of  patches  of  disseminated  myelitis. 
Vulpian  also  describes  a  case  of  variola  where  atrophy  of  the 
deltoid,  due  probably  to  a  localised  poliomyelitis,  occurred. 
But  in  opposition  to  the  numerous  cases  where  the  clinical 
phenomena  of  a  post-febrile  paralysis  are  such  as  indicate  a 
lesion  of  the  poliomyelitic  or  ascending  type,  there  are  some 
observations  on  record  where  the  most  careful  post-mortem 
examination  has  been  completely  negative  with  reference  to  any 
spinal  lesion,  whilst  the  peripheral  nerves  were  the  seat  of 
distinct  neuritic  changes.  Are  we  to  argue  from  this  the  direct 
nature  of  the  peripheral  lesion  ?  or  does  not  analogy  compel 
us  rather  to  assume  the  previous  occurrence  of  primary  cen- 
tral lesions  to  which  the  neuritic  processes  were  secondary? 
The  slight  nature  of  these  lesions,  whilst  sufficient  to  explain 
interference  with  the  trophic  functions  and  consequent  peri- 
pheral changes,  would  explain  also  their  early  disappearance. 
Indeed,  why  should  there  not  be  "  functional  "  affections  of 
the  trophic,  as  well  as  of  the  motor  and  sensory,  centres  ? 

The  author,  alluding  to  the  possible  action  of  febrile 
temperatures  in  setting  up  molecular  changes  in  the  central 
grey  matter,  shows,  on  the  authority  of  Dr.  Eenaut,  that  its 
hortensia,  or  pinkish  discoloration,  so  often  found  after  acute 
disorders,  is  due  to  an  actual  staining  by  the  dissolved  haemo- 
globin. .  Might  not  this  substance  play  the  part  of  a  poison, 
interfering  with  the  nutrition  of  cells,  and  giving  rise  to  the 
various  nervous  disturbances  observed  in  such  cases  ?  It  must 
not  be  forgotten  either  that  Meynert  and  other  observers  have 
recorded  structural  changes  in  the  grey  matter,  resembling  in 
some  particulars  the  alteration  produced  in  myelin  by  over- 
heating. 

With  reference  to  the  direct  influence  of  the  specific  poisons 
of  the  various  fevers  on  the  nervous  centres,  Dr.  Landouzy 
thinks   that  the  ischialgia,  so   characteristic  in  some   cases, 


238  CRITICAL   DIGESTS   AND 

might  very  well  be  taken  as  a  proof  of  its  reality.  It  seems 
to  manifest  itself  both  by  immediate  "  functional "  disturb- 
ances and  secondary  "  irritative  "  lesions  of  the  nervous  ele- 
ments. Future  researches  will  have  to  show  the  nature  of  such 
poisons — in  diphtheria,  for  instance,  where  figured  particles 
are  so  constantly  found  in  the  blood.  The  variety  in  the 
localizations  of  such  paralyses  depends  probably  less  on  the 
acute  disease  itself  than  on  certain  individual  predisposing 
causes.  The  asthenia  of  convalescence  plays  but  a  very  insig- 
nificant part  in  the  etiology  of  post-febrile  akinesiae,  the 
extent  of  which  is  frequently  quite  out  of  proportion  to  the 
severity  of  the  constitutional  disturbance.  The  author  dis- 
cusses the  question  whether  an  ascending  neuritis  can  account 
for  the  palatal  paralysis  after  diphtheria,  and  shows  that  such 
a  theory  does  not  account  for  the  cases  where  the  disease  was 
localized  in  other  parts  of  the  body,  such  as  in  wounds  of 
the  limbs  or  trunk,  and  where,  nevertheless,  the  paralysis 
began  among  the  muscles  of  the  palate.  The  whole  theory 
of  ascending  neuritis  (or  rather  peri-neuritis,  as  Hayem  has 
shown)  is  still  very  doubtful,  and  Vulpian  inclines  to  think 
that  if  peripheral  ever  set  up  central  changes,  it  is  more 
probably  through  a  functional  disturbance  kept  up  in  the  cord. 
The  general  subordination  of  the  nerve-fibre  to  its  cell,  and 
the  fact  that  section  of  a  nerve,  for  instance,  does  not  set 
up  descending  neuritis,  but  a  peripherical  alteration  of  its 
fibres,  compel  us  to  look  on  post-febrile  neuritis  as  secondary 
to  central  changes  rather  than  direct. 

There  is  an  important  group  of  symptoms  observed  in  many 
fatal  cases  of  diphtheria,  and  referable  to  an  extension  of  the 
paralysis  to  the  branches  of  the  pneumogastric  supplying  the 
respiratory  and  circulatory  organs.  Professor  Eevilliod,  of 
Geneva,  has  expressed  himself  to  the  effect  that  frequently  the 
cause  of  death  after  tracheotomy  is  simply  a  nervous  disturb- 
ance. Yaso-motor  troubles,  changes  in  the  rhythm  of  the 
heart,  precordial  anxiety,  syncope,  etc.,  which  are  frequently 
observed  in  acute  diseases,  may  also  be  due  to  a  morbid 
condition  of  the  medulla. 

From   what   precedes,    the    principles    which    must   guide 


NOTICES  OF  BOOKS.  239 

us  in  framing  our  diagnosis  and  prognosis  of  paralyses  in 
acute  diseases  can  readily  be  gathered.  Considerable  diffi- 
culties may  occasionally  be  experienced  in  individual  cases, 
as  similar  symptoms  may  depend  upon  lesions  of  different 
nature,  locality,  and  depth.  Muscular  atrophy,  for  instance, 
may  be  due  to  a  myositic,  neuritic,  or  myelitic  process,  the 
diagnosis  of  which  may  be  at  best  doubtful  ;  whilst  the 
prognosis  necessarily  depends  upon  an  exact  knowledge  of  that 
process.  Duchenne,  by  the  way,  is  wrong  when  he  describes 
diphtheritic  paralysis  as  yielding  normal  electro-muscular  re- 
actions. The  amyotrophies  of  febrile  disease  yield  the  reactions 
of  degeneration,  like  all  others ;  but  this  fact  is  of  little  use  in 
distinguishing  neuritic  from  spinal  lesions. 

In  reference  to  the  treatment  of  febrile  akinesise,  we  must 
remember  that  in  most  cases  they  have  a  natural  tendency 
towards  recovery.  The  special  indications  in  each  case  may, 
however,  be  fulfilled  by  acting  on  general  principles. 

Before  taking  leave  of  Dr.  Landouzy's  book  we  must  mention 
a  very  full  bibliographical  index,  which  notably  enhances  its 
value.  May  we  express  the  wish,  in  conclusion,  that  in  his 
next  edition  the  author  will  revise  his  proofs  a  little  more  care- 
fully and  remove  numerous  misspellings  ?  In  several  places 
the  construction  of  the  sentences  also  will  bear  improvement. 
At  page  275  the  sense  of  the  second  sentence  is  far  from  being 
at  once  apparent. 

A.  de  Watteville. 


General  Paralysis  of  the  Insane.    By  Wm.  Julius  Mickle, 
M.D.,  M.E.C.P.     Lewis,  London,  1880. 

It  is  not  often  that  we  meet  with  a  more  painstaking  author 
than  the  one  to  whom  we  owe  this  carefully  compiled  mono- 
graph, or  one  who  more  conscientiously  records  the  theories, 
hypotheses,  and  the  guesses  at  truth  of  each  and  every  one 
who  has  mingled  in  the  maze  of  observation,  investigation,  or 
interpretation  of  this  most  interesting  and  perplexing  disease. 
If  it  was  not  much  to  the  credit  of  the  medical  profession  that 


240  CRITICAL  DIGESTS  AND 

so  remarkable  and  well-marked  a  disease  as  general  paralysis 
should  through  all  the  centuries  have  remained  unrecognized 
until,  in  the  words  of  our  author,  "  the  discovery  burst  forth 
with  full  effulgence  in  the  works  of  Bayle,"  in  1822.  We 
fear  that  the  full  effulgence  has  since  that  time  been  not  a 
little  obscured  by  rough  and  rude  observation  and  by  rash 
hypothesis.  Every  one  almost  engaged  in  the  custody  of  the 
insane  appears  to  have  thought  that  he  was  able  and  en- 
titled to  make  incursions  of  discovery  in  this  terra  incognita  of 
pathology,  even  if  he  only  brought  back  one  pebble  to  cast 
upon  the  cairn  of  ignorance,  which  Dr.  Mickle  has  taken  so 
much  trouble  to  count,  measure,  and  describe,  that  he  has 
scarcely  attempted  the  higher  and  far  more  essential  task  of  ap- 
praisement and  discrimination.  Up  to  the  middle  of  the  volume 
the  foot-notes  of  reference  constitute  quite  a  bibliography 
of  authors,  many  of  them  unknown,  or  known  only  to  be  mis- 
trusted, and  the  same  profusion  of  references  is  continued 
throughout  to  such  an  extent  that  to  anyone  not  conversant  with 
the  personality  of  its  literature,  this  preamble  of  opposing  facts 
and  discordant  opinions  greatly  detracts  from  the  real  merit  of 
the  work,  which  consists  in  the  careful  record  of  the  rich  ex- 
perience of  its  author,  and  in  his  generally  sound  and  judicious 
inferences.  Personally  we  respect  Dr.  Mickle  all  the  more  for 
this  fault  of  his  book,  just  as  we  are  compelled  personally  to  dis- 
esteem  the  psychological  author  of  the  opposite  type,  who, 
utterly  devoid  of  all  originality,  succeeds  in  writing  readable 
books  which  are  a  tissue  of  the  threads  of  thought  stolen  from 
other  men.  But  the  pleasant  thief  may  even  be  more  profitable 
reading  than  the  conscientious  compiler,  because  his  art  enables 
us  to  grasp  the  ideas  which  he  has  assimilated,  and  thus  we 
may  feed  upon  Milton  or  upon  any  other  of  the  monarchs  of 
thought,  dished  up  in  a  modern  menu,  and  we  may  reflect, 
as  Hamlet  did,  how  that  a  man  may  "  eat  of  the  fish  that  hath 
fed  of  that  worm,  that  hath  eat  of  a  king,"  to  show  that  "  a 
king  may  go  a  progress  through  the  guts  of  a  beggar." 

But  the  fault  we  find  with  Dr.  Mickle  is  that  he  contradicts 
his  name,  and  makes  not  enough  of  himself,  by  sandwiching 
his  opinions  between  the  coarse  bread  and  the  bad  butter  or 
the  oleomargarine  of  others.     It  is  with  difficulty  that  we  get 


NOTICES   OF  BOOKS.  241 

a  taste  of  them,  yet  when  we  do,  the  flavour  is  right,  for  he  is 
evidently  a  careful  observer  and  honest  thinker,  and  he  has 
grand  opportunities  of  observing  at  least  the  later  stages  of 
the  disease  about  which  he  writes ;  for  Dr.  Mickle  is  the 
medical  superintendent  of  that  proprietary  lunatic  asylum 
at  Bow  which  belongs  to  a  private  gentleman  named  By  as, 
and  in  which,  under  the  sanction  of  the  Commissioners  in 
Lunacy,  the  Government  causes  its  soldiers  who  become  insane 
to  be  incarcerated.  The  history  of  the  treatment  of  insane 
soldiers  deserves  to  be  told.  For  a  time  the  army  authorities 
borrowed  the  hospital  at  Yarmouth  from  the  navy,  but  when 
it  was  wanted  for  insane  sailors,  and  when,  moreover,  it  had  been 
discovered  that  soldiers  becoming  insane  could  not  be  got  rid 
of  by  turning  them  loose  in  the  streets  of  Chatham,  after  the 
parish  authorities  had  been  advised  that  they  must  take  care  to 
apprehend  these  loose  madmen  as  not  being  under  proper  care 
and  control — then  the  insane  soldiers  were  farmed  out  to  Mr. 
Byas,  who  has  had  the  good  sense  to  employ  Dr.  Mickle  to 
take  care  of  them.  The  army  has  hitherto  been  supposed  to 
contain  its  full  proportion  of  intemperate  and  dissolute  men, 
and  as  drink  and  dissipation  are  supposed  to  be  efficient  causes 
in  the  production  of  general  paralysis,  Dr.  Mickle  has  enjoyed 
a  wide  field  of  observation  on  the  subject  of  his  monograph, 
of  which  he  has  not  failed  to  avail  himself. 

The  first  chapter,  on  what  the  author  calls  the  Prodromes, 
valuable  as  it  may  be,  does  not  make  up  for  the  defect  we  feel 
in  the  more  important  chapter  on  Diagnosis  that  the  latter  is 
instituted  in  regard  to  the  fully  developed  form  of  the  disease, 
where  small  difficulty  is  usually  met  with,  and  little  skill 
required.  There  are  few,  if  any,  of  the  physical  prodromes 
which  may  not  prove  to  be  precursory  signs  of  other  disorders, 
or  which  may  not  pass  away  without  the  supervention  of  any 
diseases.  The  most  important  and  significant  precursor  is 
"  sudden  unforeseen  moral  falls,  of  which  theft  is  one  of  the 
most  frequent,  which  occur  to  those  hitherto  without  reproach. 
In  the  history  of  many  a  case  do  we  find  that  some  moral  or 
other  mental  change  in  the  patient  has  been  noticed  long 
before  the  recognized  onset  of  the  disease."  We  may  observe 
in  passing  that  these  so-called  moral  falls  appear  to  indicate 

VOL.    III.  R 


242  CRITICAL  DIGESTS  AND 

general  change  of  the  mental  faculties,  and  that  this  kind  of 
thief  does  not  steal  because  his  desire  has  overcome  his  sense 
of  right,  but  simply  because  he  has  misjudged  his  relation  to 
the  property  of  others.  The  so-called  moral  perversion  is  in 
truth  insidious  dementia,  notwithstanding  the  fact  that  no  little 
ingenuity  and  design  are  sometimes  displayed  in  obtaining  the 
proposed  end.  But  in  judging  of  the  medical  purport  of 
"  sudden  unforeseen  moral  falls  "  without  the  accompaniment 
of  physical  symptoms,  the  mental  physician  has  great  need  to 
beware  lest  he  be  used  as  a  cat's-paw  on  behalf  of  some  real 
criminal  who  may  for  long  have  broken  many  or  most  of  the 
Commandments. 

In  the  important  chapter  on  symptoms,  as  distinct  from 
precursors,  we  are  dreadfully  puzzled  to  know  just  where  we 
are,  in  consequence  of  the  author's  habit  of  running  a  little 
way  after  everyone's  lead,  and  then  forsaking  it  for  some  new 
track.  The  one  important  thing  to  do  was  to  fix  and  define 
the  very  earliest  symptoms  by  which  this  fatal  disease  can  be 
definitely  recognized ;  but,  instead  of  doing  this,  the  author 
discusses  the  stages  and  periods  of  the  disease  according  to 
the  diverse  opinions  of  several  authors,  in  whose  observations 
and  opinions  we  should  have  much  less  confidence  than  in 
his  own,  if  he  would  only  have  given  them  without  all  this 
frippery  of  reference.  It  is  a  mistake  to  describe  a  continuous 
disease  like  General  Paralysis  as  if  it  had  stages  like  a  coach, 
or  even  like  an  exanthematous  fever;  and  it  is  an  abuse 
of  language  to  discuss  periods  in  a  progress  where  there  is 
but  one  period — that  is,  death.  That  which  would  be  most 
precious  in  practice,  but  which  we  do  not  get,  would  be  an 
original  investigation  into  the  earliest  trustworthy  signs  and 
symptoms,  and  into  the  just  value  of  those  which  are  more  or  less 
reliable.  In  default  of  such  guidance,  mistakes  are  constantly 
being  made  even  by  practitioners  of  some  experience,  while 
by  the  profession  at  large  the  early  recognition  of  this  disease 
is  a  task  as  hopeless  as  it  is  important.  In  default  of  such 
knowledge,  it  can  be  no  matter  of  surprise  that  the  chapter  on 
Diagnosis  points  to  the  roughest  discrimination  from  the  most 
unlike  diseases.  It  may  be  worth  while  to  tell  a  man  that  if 
he  walks  upon  his  own  shadow  he  will  not  go  to  the  south 


NOTICES  OF  BOOKS.  243 

in  these  latitudes ;  but  in  medicine  an  exact  semeiology  is  a 
mariner's  compass  which  supersedes  the  need  of  such  rough 
directions ;  and  for  once  in  a  way  the  author  does  object  to  one 
of  his  recent  authorities,  Voisin,  for  including  senile  dementia 
in  General  Paralysis,  and  to  the  "  regrettable  tendency  in  this 
direction,  with  the  result  of  thrusting  into  the  domain  of 
general  paralysis  a  host  of  various  senile  cases  alien  to  it." 

In  his  account  of  the  microscopical  appearances,  as  described 
by  Mierzejewski  and  others,  the  author  says  : — 

"  So  great  is  the  variety  of  morbid  appearances  described, 
and  of  the  localities  said  to  be  principally  affected^  that  I 
propose  to  trace  the  changes  throughout  the  whole  central 
nervous  system,  beginning  at  the  brain  as  a  matter  of  con- 
venience, and  without  prejudice  as  to  what  part  of  the  nervous 
system  is  the  primary  or  principal  seat  of  the  disease — a 
question  as  to  which  the  most  conflicting  replies  have  been 
returned  by  workers  in  nervous  pathology.  With  facility  one 
might  dogmatize;  but  in  the  present  imperfect  and  shifting 
state  of  our  knowledge,  I  think  it  better  to  quote  several 
observations,  even  at  the  risk  of  being  thought  tedious." 

Therefore  with  regard  to  the  Pathology  and  the  Pathological 
Physiology,  we  are  duly  informed  of  the  views  entertained  by 
Lubinoff,  Luys,  Lionville,  Laseque,  Linas,  Landors,  Lusana, 
Lemoine,  Landouzy,  and  other  writers  of  as  great  authority ; 
the  result  being  that  "  our  attention  is  claimed  by  a  conflict 
of  opinion  as  to  whether  the  essential  pathological  change 
in  general  paralysis  is  principally  and  primarily  of  a  more  or 
less  frank  inflammatory  nature,  or  principally  and  primarily 
of  a  degenerative  nature."  And  it  is  no  wonder  that  the 
author  concludes  that,  "confronted  with  these  various  and 
often  irreconcilable  views,  we  may  proceed  to  examine  the 
subject  anew."  The  wonder  rather  is  that  he  should  have 
imitated  the  frequent  habit  of  many  insane  patients  by  such 
promiscuous  accumulation. 

Forced  in  this  manner  to  examine  the  subject  anew,  the 
author  proposes  a  view  of  his  own,  which  is  that  "  the  morbid 
process  in  the  nervous  system  first  deranges  and  then  destroys, 
or  tends  to  destroy,  the  functions  of  the  parts  affected. 

"  In   the   vast    majority   of  cases    the    cerebral    cortex   is 

R  2 


244  CKITICAL  DIGESTS  AND 

primarily  affected,  the  meninges  usually  being  more  or  less 
involved  almost  simultaneously ;  in  many  cases  the  morbid 
process  is  most  active  in  circumscribed  regions;  the  convo- 
lutions of  the  frontal  and  parietal  lobes  suffer  more  than  other 
parts."  There  is  repeated  and  more  or  less  persistent  cerebro- 
meningeal  hyperemia ;  distention  of  the  vessels,  circulatory 
impediments,  irritative  over-growth  of  the  connective  nuclei 
of  the  walls  of  the  vessels,  and  probably  also  of  the  neuroglia  ; 
while  others  of  the  nuclei  and  cellules,  often  termed  embryo- 
plastic,  or  their  materials,  are  perhaps  directly  effused.  Other 
changes  from  the  lowered  standard  of  the  local  processes  of 
nutrition  are  wandering  of  white  blood-corpuscles,  and  escape 
or  extravasation  of  red  blood-corpuscles ;  tendency  to  diffuse- 
ness  of  all  the  morbid  processes,  and  thickening  opacity  and 
oedema  of  the  superjacent  meninges ;  the  nerve-cells  failing 
in  their  nutrition,  and  hence  their  swelling  cloudiness  and 
final  degeneration.  Then,  if  a  chronic,  mild,  adhesive  form  of 
inflammation  sets  in,  fibrinous  effusions  and  production  of 
connective  tissue  assist  in  more  completely  involving  the 
nerve-cells  and  in  tying  down  the  membranes  to  the  cortex. 
"These  changes  proceed  in  the  usual  degenerative  course, 
and  finally,  as  a  result  of  them,  we  find  the  processes  of  the 
nerve-cells  cut  off  by  the  way — the  cells  themselves  atrophic 
and  degenerate  —  the  blood-vessels  fatty,  calcareous,  pig- 
mented, and  misshapen,  and  the  former  hyperplastic  neuroglia 
now  atrophied." 

Such  is  the  author's  "own  view,"  somewhat  abbreviated, 
of  the  pathological  changes ;  and  this  "  own  view,"  as  it  bears 
upon  the  course  of  the  disease,  is  continued  for  many  pages 
well  worth  reading  and  reflecting  upon.  We  can  only  regret 
that  the  volume  does  not  contain  a  much  larger  proportion  of 
statements,  suggestions,  and  opinions  from  the  same  source. 
The  chapter  on  Therapeutics,  which  comes  to  us  nearly 
undiluted  by  references,  is  very  sound  and  sensible.  The 
author  thinks  highly  of  yeratrum  viride  during  the  earlier 
periods,  and  of  perchloride  of  iron  throughout ;  and  he  thinks 
prolonged  artificial  suppuration  likely  to  do  good,  but  has 
not  had  the  courage  to  try.  We  have  frequently  used  it, 
and  have  been  convinced    the  progress  of  the  disease   was 


NOTICES  OF   BOOKS.  245 

retarded  thereby ;  but,  like  Dr.  Mickle,  we  have  never  seen 
any  treatment  followed  by  any  better  result  than  a  temporary 
remission  of  symptoms.  Still  there  can  be  no  doubt  that 
appropriate  treatment  will  greatly  diminish  the  apparent 
sufferings  of  the  patient,  or  at  least  render  them  less  incon- 
venient and  distressing  to  those  about  him. 

The  volume  is  concluded  by  a  small-type  Appendix  of  cases, 
in  which  the  author  attempts  to  establish  five  varieties  of  the 
disease,  and  it  forms  a  valuable  record  of  well-observed  facts. 
It  seems  to  be  pretty  certain  that  there  are  no  kinds  of  general 
paralysis  distinct  from  each  other.  Every  case  is  dissimilar, 
within  certain  limits,  from  all  other  cases,  but  it  may  be 
doubted  whether  each  group  does  not  pass  by  insensible  grada- 
tions into  other  groups ;  and  the  author  fully  recognizes  the 
principle  that  the  essential  pathological  process  is  not  multi- 
form ;  and  if  he  only  makes  use  of  his  attempt  to  group  the 
individual  cases  as  a  means  of  investigating  the  causes  of  their 
difference,  the  labour  may  be  well  repaid.  During  further 
inquiry  he  will  probably  have  to  rearrange  his  groups  many 
times,  in  order  to  make  them  fit  in  with  the  varying  facts  he 
may  meet  with.  The  groups  Nos.  3  and  4  seem  to  be  mainly 
based  upon  the  encephalic  localities  of  the  pathological  changes. 
No.  2,  upon  the  chronicity  and  mildness  of  the  disease. 
No.  5,  upon  a  local  cortical  induration.  No.  1,  upon  gene- 
ralized and  symmetrical  affections  of  the  hemispheres,  with 
adhesion  and  decortication  of  the  cerebellum,  but  the  plan 
is  too  complex  to  promise  success  as  a  method  of  investi- 
gation. The  groups  should  have  been  formed  on  some  con- 
sistent plan :  for  instance,  the  localities  affected,  or  the  kinds 
of  morbid  process.  Grouping  in  a  methodical  manner  is  by 
no  means  an  inefficient  means  of  investigation,  but  grouping 
according  to  any  characteristics  of  the  most  diverse  kind  which 
seemingly  present  themselves  will  be  likely  to  disappoint  the 
hopes  and  efforts  of  the  observer. 

John  Chaeles  Bucknill. 


Clinical  Caass. 

CASE  OF  MICROCEPHALIC  IDIOCY. 

,  BY   A.   R.   URQUHART,  M.D., 
Medical-Superintendent,  Murray's  Royal  Asylum,  Perth. 

In  addition  to  the  two  cases  of  Microcephalic  Idiocy  described 
by  Dr.  H.  R.  0.  Sankey  in  this  Journal  (<  Brain,'  October  1878), 
there  is  at  present  a  third  patient  similarly  affected  under  the 
care  of  Dr.  Parsey  (Warwick  County  Asylum). 

E.  F.  was  admitted  into  the  Warwick  County  Asylum  on 
the  20th  of  September,  1876,  from  a  remote  workhouse,  where 
she  had  been  detained  for  five  years. 

Mr.  Hitchens,  of  Shipston-on-Stour,  has  kindly  obtained  the 
following  facts  from  her  father.  Her  parents  were  not  related 
before  marriage,  and  were  of  average  intelligence,  sober  and 
industrious.  Her  father  is  now  seventy-four  years  of  age,  a 
hale  old  field-worker.  Her  mother  died  of  phthisis  twenty- 
five  years  ago,  was  always  delicate,  and  for  the  last  fifteen 
years  of  her  life  did  but  little  work. 

She  had  seven  children,  three — still  alive  and  without  mental 
defect — born  before  E.  F.  Two  bom  after  E.  F.  were  also 
healthy,  but  one  of  them  died,  set.  16,  of  rheumatic  fever. 
The  last  child  was  seven  years  younger  than  the  patient,  and 
had  an  abnormally  small  head,  though  not  so  small  as  hers. 
This  girl  had  more  intellectual  capacity  than  E.  F.,  but  she 
never  walked,  and  suffered  from  general  marasmus  till  her 
death,  when  nine  years  old. 

The  family,  as  a  rule,  appear  to  be  fairly  healthy.  The  only 
ascertained  history  of  nervous  disease  occurred  in  a  niece  of 
the  mother's,  who  had  a  paralytic  seizure. 

During  Mrs.  F.'s  pregnancy  with  E.  F.  she  had  no  disease, 
and  met  with  no  accident ;  and  there  is  no  history  of  any 
extraordinary  maternal  impression.  At  birth  the  cranium  of 
E.  F.  was  noticed  to  be  very  small,  the  medical  attendant 
stating  that  her  brains  were  all  in  the  back  of  her  head. 


CLINICAL   CASES.  247 

When  in  the  workhouse  she  was  very  passionate,  noisy,  and 
excitable  ;  and  was  reported  in  the  certificate  of  insanity  to  be 
getting  more  unmanageable. 

On  her  admission  she  was  in  a  similar  condition  to  her 
present  state,  though  during  her  residence  here  she  has  become 
quieter  and  more  tractable,  and  has  also  improved  in  her 
habits. 

She  is  now  forty  years  of  age,  but  looks  considerably  older. 
Her  attitude  is  peculiar.  She  perches  herself  on  the  edge  of  a 
chair  in  a  simian  posture,  the  hands  being  invariably  crossed 
on  the  breast,  constantly  intertwining  in  a  nerveless,  purpose- 
less way  to  an  accompaniment  of  a  rhythmical  swaying  of  the 
body  to  and  fro.  Her  back  is  bent  till  her  head  appears  to 
be  set  on  at  right  angles  to  her  body,  and  her  neck  is  usually 
on  the  full  stretch ;  she  is  either  craning  forward  in  her  con- 
tortions or  her  head  is  bent  down  to  the  utmost.  In  summer 
her  chosen  place  is  by  the  corridor  door,  in  winter  hard  by 
the  fire.  She  is  shrivelled  and  aged-looking.  The  wrinkles 
on  her  face  are  deep,  and  her  breasts  are  withered  and  pendu- 
lous. She  is  slightly  built,  with  small  bones,  and  insignificant 
muscular  development.  Her  habit  of  stooping  has  brought  her 
shoulders  forward  to  the  utmost,  but  otherwise  she  presents  no 
extraordinary  deformity  of  body  or  limbs,  save  for  a  slight 
inequality  in  the  length  of  forearm  and  hand — the  right  being 
the  longer  by  half  an  inch.  Her  head  at  once  attracts  atten- 
tion by  its  minute  size,  which  somewhat  luxuriant  grey  hair 
is  perfectly  inadequate  to  compensate  for.  Her  complexion  is 
sallow,  and  her  expression  in  repose  fatuous  in  the  extreme. 
At  other  times  it  varies  between  fear  and  pleasure,  rarely 
showing  attention  or  curiosity. 

The  shape  of  her  head  is  oxycephalic,  tapering  to  a  cone- 
like summit.  Her  nose  is  long  and  prominent,  surmounted  by 
well-developed  frontal  sinuses,  immediately  above  which  the 
frontal  bone  bends  suddenly  backwards,  and  slants  upwards  on 
a  parallel  plane  with  the  nose.  The  remaining  upper  incisors 
project  from  the  alveolus  and  the  chin  suddenly  retreats 
beneath  a  wide  and  capacious  mouth.  The  cheek-bones  form 
the  widest  part  of  the  face.  The  occipital  spine  is  boldly 
marked,  and  forms  an  excellent  tubercle  for  measuring  from. 
The  cranial  sutures  are  closed. 

She  walks  in  an  exceedingly  clumsy  manner,  lifting  her 
feet  high  from  the  ground  and  rolling  at  each  step,  She  runs 
but  seldom,  and  when  she  does,  it  is  with  an  indescribable 
shuffle,  with  head  thrust  out  in  front  and  a  feeling  of  tottering 
insecurity.  All  her  motions  are  clumsy  and  express  a  want 
of  co-ordinating  power.  Notwithstanding  she  possesses  a  fair 
amount  of  strength,  and  in  anger  has  been  known   to  pull 


248  CLINICAL  CASES. 

another  patient  down  on  the  floor.  Her  grasp  is  apparently  feeble 
under  ordinary  circumstances,  and  her  intelligence  so  limited 
that  she  cannot  exert  it  on  command.  It  is  easy,  for  instance, 
to  pull  a  tea-cup  out  of  her  hands,  but  the  nurses  sometimes 
find  it  rather  difficult  to  persuade  her  to  enter  a  bathroom- 
door.  She  claps  her  hands  sometimes,  but  without  eliciting 
much  noise.  Though  ravenous  at  meal  times,  her  haste  in 
eating  is  owing  to  the  quantities  she  stuffs  in  her  mouth,  not 
to  the  rapidity  of  arm  motion. 

Her  days  are  spent  sitting,  as  above  described,  on  a  chair,  from 
which  she  very  rarely  moves  unless  when  summoned  to  meals 
or  to  bed.  She  is  passionate  when  tormented,  but  appears  on 
the  whole  to  be  of  an  amiable  temper,  with  the  characteristic 
confiding  simplicity  of  idiocy. 

With  regard  to  her  bodily  condition,  she  is  in  fair  health. 
On  her  admission  she  was  often  sick  after  food,  but  now  this 
rarely  happens.  Her  tongue  is  clean  and  moist,  her  appetite 
good,  her  bowels  regular.  The  teeth  are  yellow  and  chalky, 
and  several  have  dropped  out.  The  palate  is  low  and  smooth. 
Her  skin  is  moist  and  free  from  eruptions. 

The  organs  of  circulation  present  the  usual  characteristics  of 
congenital  idiocy.  The  pulse  is  slow,  weak  and  small.  The 
heart's  impulse  is  feeble,  the  sounds  normal.  The  feebleness 
of  circulation  is  manifested  by  the  constant  swelling,  oedema, 
and  lividity  of  the  feet  and  legs,  which  sometimes  indeed 
necessitates  her  detention  in  bed. 

Eespiratory  organs  apparently  normal.  The  inspiration  is 
extremely  shallow  and  feeble. 

She  used  to  menstruate  at  irregular  intervals  till  about 
three  years  ago,  when  the  catamenia  suddenly  ceased  for  six 
months,  at  the  end  of  which  time  she  suffered  from  a  menor- 
rhagic  attack,  after  which  all  menstruation  ceased.  She  has 
never  been  known  to  manifest  any  sexual  feelings.  Her 
genital  organs  are  apparently  normal.  Her  sight  is  intact,  for 
long  and  short  range  of  vision.  Hearing  is  also  apparently 
perfect.  Smell  is  but  feebly  developed.  Taste  is  evidently 
present — she  prefers  bread  and  treacle  to  bread  and  butter — 
and  touch  is  sensitive  if  not  indeed  hyperaesthetic. 

Her  intelligence  is  extremely  low.  She  recognises  strangers, 
if  in  a  different  garb  to  the  ordinary  asylum  dress ;  and  she 
knows,  at  any  rate,  one  patient  who  is  her  especial  aversion. 
She  recognises  her  name,  also  simple  words  and  phrases — as, 
dinner,  bed,  bath,  music,  &c. — but  her  vocabulary  is  extremely 
limited. 

She  is  perfectly  helpless  in  regard  to  dressing  herself.  The 
only  use  she  can  make  of  her  hands  is  in  feeding ;  she  can 
use  a  spoon. 


CLINICAL  CASES.  249 

Her  language  is  confined  to  interjections ;  her  whole  stock 
being,  "Oh  dear!"  "Now  then!"  "Ah=Yes!"  "Hulloa!" 
"  Ah  ! "  and  "  No."  And  these  are  pronounced  so  indistinctly 
that  it  requires  some  experience  to  determine  which  is  which. 
When  asked  to  go  to  the  bath,  she  will  sometimes  say 
"No."  She  is  fond  of  pretending  that  she  is  ill,  saying, 
"  Ah ! "  with  indrawn  breath  and  a  very  good  imitation  of 
suffering  expressed  by  hands  pressed  on  stomach  and  piteous 
noise. 

Attention  is  hardly  present.  It  requires  considerable  motor 
power  to  rouse  her  attention,  and  then  it  is  but  a  momentary 
exhibition.  For  instance,  she  can  be  roused  to  scream  at  the 
sight  of  a  penknife  being  opened,  but  would  take  no  notice  of 
a  dog  in  unaccustomed  attitudes. 

There  does  not  appear  to  be  any  imitative  faculty  in  force. 

She  has  no  fund  of  amusements,  no  fondness  for  any  toy  or 
ornament.  A  doll  will  lie  in  her  lap  unheeded,  and  picture- 
books  are  beyond  her  range  entirely. 

She  seems  to  have  a  preference  for  little  children,  and  has 
on  more  than  one  occasion  given  them  portions  of  bread  and 
butter. 

Her  memory  is  certainly  rudimentary.  She  remembers 
having  an  abscess  in  her  leg  opened  by  a  lancet  two  years  ago — 
witness  her  screams  on  seeing  a  penknife ;  she  certainly  recog- 
nises tape  and  callipers,  and  has  a  lively  recollection  of  my 
stealing  her  bread  and  butter  at  tea. 

Her  fondness  for  music  is  remarkable.  This  is  evidently  not 
a  mere  liking  for  noises ;  but  she  can  really  appreciate  musical 
rhythm.  Her  great  delight  is  to  hear  the  band  play,  and 
when  the  music  is  in  full  swing  her  contortions  are  most  pro- 
nounced, and  her  grunty  noises  are  at  their  loudest. 

Identity  is  present — evidenced  by  her  knowledge  of  her  own 
ward,  her  own  bed,  and  her  own  seat. 

She  would  pay  no  attention  to  the  calls  of  nature ;  and  is 
only  preserved  clean  by  being  taken  to  the  closet  daily.  She 
never  makes  any  attempt  to  find  her  way  there  herself,  but 
when  there  gives  no  farther  trouble. 

She  is  very  timid  and  easily  frightened. 

Exhibits  no  affection  or  preference  for  any  single  patient. 
In  fact  her  habits  are  perfectly  solitary. 

She  still  continues  very  passionate,  though  her  oppor- 
tunities of  showing  this  have  been  much  diminished.  She 
is  also  revengeful  as  regards  one  fellow-patient  only.  This 
girl  has  a  most  objectionable  habit  of  staring  into  her  neigh- 
bours' faces  from  a  very  close  proximity,  and  E.  F.  will  at 
once  take  the  offensive  on  her  approach.  With  an  evident 
memory    of    former    encounters,   she    makes    hideous    noises 


250 


CLINICAL   CASES. 


and  clutches  at  the  object  of  her  wrath  with  a  ferocity  that 
could  scarcely  be  credited  to  her  slight  figure  and  nerveless 
fingers. 

Occasionally,  though  now  not  so  frequently  as  in  former 
years,  she  lies  down,  refuses  to  move,  and  .has  to  be  carried  to 
bed. 

Curiosity  is  very  faintly  developed. 

Pleasure  is  manifested  by  smiles  and  a  quickened  rocking  of 
the  body,  and  a  more  rapid  interlacing  of  fingers.  This  is 
chiefly  manifested  on  hearing  music. 

She  often  exhibits  mortification  and  jealousy  when  she  is 
overlooked  by  the  nurse  or  her  fellow-patients  going  out  to  the 
garden.  At  these  times  she  becomes  noisy,  and  is  only  pacified 
on  being  allowed  to  join  her  neighbours. 


DIAGRAM — HALF   LIFE   SIZE — OF  HEAD   MEASUREMENTS. 


Sympathy,  and  all  the  more  complex  psychical  phenomena 
are  quite  beyond  her  ken.  In  fact  her  mental  capacity  might 
be  rudely  gauged  at  something  below  that  of  a  fairly  intelli- 
gent house-dog. 

She  sleeps  in  the  foetal  position,  covered  entirely  by  the 
bedclothes. 


CLINICAL   CASES. 


251 


MEASUREMENTS. 


/ 


Height 
Weight 

Curves    . 

Forehead 


Diameter 


Callipers 


Curves 


4  feet  9J  inches. 
85  1b. 


Ears 


Palate  width    . 

Length    . 

Breadth  . 

Length  of  Arm 
„         Forearm 
„         Hand 
Thigh 
»         Leg 
„         Foot 

Round  Arm 
„    Calf      . 

Width  of  Shoulders 
„       Pelvis 


Circumference  (a  b) 

Antero-posterior  (a  b) 

Bi-auricular  (c  c)    . 

Breadth  (e  b) 

Height  (a  d)  . 

Longitudinal  (a  b)  . 

Transverse  (ff) 

Bimastoid  (G  G) 

Bizygomatic  (h  h)  . 

Fronto-mental  (a  i) 

Occipitofrontal  (b  d) 

Occipito-superciliar  (b  a) 

Occipito-iiasal  (b  k) 

Occipito-alveolar  (b  l) 

Tragus  to  chin  (c  i) . 

„        Alveolus  (ol) 
„        Nasal  prominence  (c  k) 
„        Superciliary  ridge  (c  a) 
„        Top  of  forehead  (c  d) 
„        Occiput  (o  b)    . 
„        Chin  (o  i) 
„        Alveolus  (c  l) 
„        Tip  of  nose  (c  k) 
„        Superciliary  ridge  (c  a) 
„        Top  of  forehead  (c  d) 
Occiput  (cb)    . 

11  inches. 

OS 


1? 
11 

9 

6J 
16} 
17* 

10J 
10| 

10J 


16J  inches. 
9 

10  „ 

3?  „ 

If  n 

5|  „ 

H  » 

4  „ 

*a  » 

4  „ 

51  „ 

5f  „ 

71  „ 

6i  „ 

To  •■ 


31 
51 
4f 

H 

4| 


CASE  OF  CEREBRAL  TUMOUR. 

BY   ARTHUR   W.   FOX,  M.B. 

Physician  to  the  Eastern  Dispensary,  and  Bellott's  Mineral-  Water  Hospital,  Bath  , 

and 

ERNEST  FIELD,  M.B. 

Physician  to  the  Eastern  Dispensary,  Bath. 

H.,  a  shoemaker,  aged  42  years,  consulted  me  on  September  14th, 
1878.  He  was  of  middle  height,  muscular  build,  pale  com- 
plexion, and  had  a  stolid  expression  of  countenance. 

He  stated  that  nine  years  ago,  when  he  was  fighting  with 
another  man,  he  tumbled  down  and  was  unconscious,  but  that 
he  was  not  knocked  down.  His  wife  informed  me  that  the  true 
version  of  the  story  was,  that  he  had  been  playing  at  cards  with 
some  other  men,  when  a  quarrel  arose,  which  ended  in  his  being 
knocked  down  and  kicked  violently  in  the  head,  and  that  he 
was  so  stunned  as  to  be  unconscious  for  a  long  time.  Two 
years  and  a  half  ago,  when  at  breakfast,  his  "face  turned 
very  pale,  and  his  lips  black,"  but  he  was  not  unconscious, 
neither  had  he  headache,  or  twitching  of  his  limbs,  but  he  felt 
giddy.  Since  then  he  has  often  had  these  "  pale  fits,"  some- 
times as  many  as  two  or  three  attacks  in  a  day.  On  one 
occasion  a  fortnight  elapsed  without  his  having  any.  He  was 
obliged'  to  give  up  work  a  fortnight  before  Christmas,  1877,  on 
account  of  violent  pain  in  his  head  in  the  frontal  region ;  for 
this  he  became  an  out-patient  at  the  United  Hospital,  when,  as 
he  required  to  be  visited  at  his  own  home,  he  was  under  the 
care  of  Dr.  Field,  who  found,  upon  examination  of  his  optic 
discs,  double  optic  neuritis ;  and,  coupling  this  fact  with  the 
violent  headache,  he  formed  the  opinion  that  the  case  was  one 
of  cerebral  tumour. 

The  patient  was  able  to  read  up  to  the  date  of  a  month 
before  Christmas,  1877 ;  since  then  he  has  gradually  become 
blind.  There  was  no  history  whatever  of  syphilis,  but  he  had 
gonorrhoea  many  years  ago.    He  drank  to  excess  when  he  was 


CLINICAL  CASES.  253 

younger,  but  has  not  done  so  for  years.     His  mother  died  of 
phthisis,  and  he  has  a  cousin  insane. 

Present  State. — Mr.  Mason,  who  recently  examined  his  eyes 
at  the  eye  infirmary,  describes  his  discs  as  in  a  state  of  white 
atrophy.  His  pupils  are  contracted,  equal.  Smell  unmistakably 
blunted  on  both  sides.  Taste  fair.  Hearing  good.  Memory 
affected  as  to  recent  events,  but  good  for  what  happened  some 
time  ago.  Sleeps  well.  Complains  of  constant  headache  in 
frontal,  and  to  some  extent  parietal  region,  but  he  is  no 
longer  liable  to  the  violent  paroxysmal  exacerbations  he 
suffered  from  when  he  was  under  Dr.  Field's  notice.  Tongue 
protruded  straight,  and  moved  well  in  all  directions ;  organ  in 
a  state  of  fibrillary  tremor.  No  appreciable  tremor  of  palate. 
No  affection  of  speech.  No  nystagmus.  Fine  tremor  of  both 
arms,  which  grows  coarser  upon  an  attempt  at  voluntary  move- 
ment. Grasp  of  hands  equal.  No  paralysis  of  face,  limbs,  or 
sphincters.  This  is  neither  anaesthesia  nor  hyperesthesia.  The 
reflex  excitability  of  skin  and  tendons  is  normal.  Although 
blind,  he  is  able  to  touch  with  precision  various  parts  of  his 
face  and  body.  Appetite  good;  never  any  nausea.  Bowels 
regular.  Urine,  specific  gravity,  1027  ;  trace  of  sugar.  Other 
systems  apparently  normal. 

October  2nd.  Had  a  severe  general  convulsion.  When  I 
saw  him  he  had  regained  consciousness;  he  complained  of 
severe  pain  in  his  head  in  the  frontal  region.  His  face  and 
head  were  dripping  with  perspiration. 

November  3rd.  According  to  his  wife's  statement,  he  had  an 
attack  without  convulsion,  in  which  he  was  unconscious ;  when 
I  saw  him,  shortly  afterwards,  he  was  quite  conscious.  In 
addition  to  the  usual  tremor  of  his  arms,  there  was  general 
tremor  of  head  and  body  ;  no  nystagmus. 

November  11th.  Another  severe  fit,  in  which  he  was  un- 
conscious. His  wife  described  it  as  follows  :  First,  rigidity  of 
both  legs,  but  the  right  leg  the  most  rigid ;  left  arm  flexed  and 
rigid  ;  head  bent  forward :  this  was  followed  by  shaking  all 
over.  Unfortunately  there  is  no  note  of  the  period  when  he 
became  unconscious.  His  breathing  was  loudly  stertorous. 
When  I  saw  him,  half  an  hour  afterwards,  he  had  regained  con- 
sciousness. There  was  no  paralysis,  but  there  was  a  coarse 
tremor  of  arms  and  legs ;  none  of  head,  and  no  nystagmus. 
Nothing  could  convince  him  that  he  was  in  his  own  house. 

December  2nd.  Yomited.  In  the  evening  had  a  severe  con- 
vulsive seizure,  and  was  a  long  time  unconscious.  At  the 
commencement  there  was  rigidity  of  both  legs,  and  both  arms 
were  flexed. 

January  21st.  Has  lately  had  what  his  wife  terms  "  sleepy 
fits,"  and  several  of  his  former  "  white  fits."    Her  description  of 


254  CLINICAL   CASES. 

a  general  convulsive  attack  he  had  to-day  is  as  follows :  "  His 
face  first  reddened,  and  he  then  became  unconscious.  His  eyes 
protruded,  and  his  face  became  pale.  His  eyes  then  rolled, 
and,  at  the  same  time,  his  limbs  became  rigid.  This  was 
followed  by  shaking  all  over."  His  wife  also  told  me  that 
when  he  is  in  his  sleepy  fits,  in  which  he  is  only  partially  un- 
conscious, his  "  head  is  drawn  backwards  when  the  fits  begin," 
and  at  the  same  time  he  has  a  "  twitching  of  his  left  shoulder." 
She  describes  it  as  an  upward  movement.  When  I  saw  him 
some  time  after  his  severe  attack,  he  told  me  that  he  had  no 
headache ;  he  appeared  much  as  usual.  His  wife  states  that 
when  he  walks  he  tends  to  fall  backwards.  He  had  some 
difficulty  to-day  in  passing  water. 

April  11th.  Has  lately  had  several  "sleepy  fits"  and 
"  white  fits,"  but  has  had  no  seizure  in  which  he  has  been  com- 
pletely unconscious.  The  tremor  of  his  arms  and  the  fibrillary 
tremor  of  his  tongue  remain  about  the  same  as  when  I  first 
saw  him.  On  this  occasion  the  tremor  of  right  arms  is  coarser 
than  that  of  left.  Grasp  of  right  hand  stronger  than  that  of 
left.  Eecently,  when  he  has  wished  to  pass  water,  he  has 
occasionally  been  unable  to  do  so,  but  when  the  stream  comes 
he  is  unable  to  control  it. 

From  this  date  I  never  saw  him  again,  as  he  went  into  the 
union  under  the  care  of  my  friend  Mr.  Biggs.  I  learnt 
subsequently,  that  during  his  residence  in  the  union,  he  com- 
plained but  seldom,  if  ever,  of  headache,  and  he  became  very 
fat.  He  had  no  paralysis.  He  was  happy,  but  had  a  delusion 
that  he  had  been  at  home  "  mending  and  making  boots,"  and 
"  that  he  was  put  in  the  wrong  bed," — an  old  delusion  of  his. 
He  never  had  any  delusions  of  grandeur,  or  apparently  any 
feeling  of  exaltation.  He  died  in  a  general  convulsive  seizure 
on  March  25th,  1880,  at  6.30  a.m. 

The  post-mortem  was  made  fifty-three  hours  after  death,  on 
March  29th,  by  Dr.  Field,  in  the  presence  of  Mr.  Biggs  and 
myself.  The  following  account  is  taken  from  Dr.  Field's  notes : 
— Scalp  very  thick,  much  congestion  of  vessels.  Cranium 
moderately  thick  and  hard,  contents  tightly  packed  ;  some 
flattening  of  convolutions,  vessels  of  membranes  full.  Whole 
brain  rather  firmer  than  normal,  but  anterior  right  half  of 
hemisphere  very  hard.  On  making  horizontal  sections  through 
the  right  hemisphere,  a  cribriform  appearance  was  seen  in  the 
white  matter  covering  the  corpus  striatum,  and  this  was  still 
more  marked  in  the  septum  separating  the  anterior  part  of  the 
two  lateral  ventricles,  where  cystoid  spaces  existed  in  numbers, 
some  the  size  of  a  threepenny  piece,  and  one  that  of  a  sixpence ; 
these  spaces  contained  a  colourless  fluid.  The  cribriform  tissue 
was  much  thickened,  and  much  firmer  than  the  rest  of  the  brain. 


CLINICAL  CASES.  255 

The  right  corpus  striatum  was  very  hard,  and  larger  than  the 
left,  but  in  colour  was  normal,  as  if  produced  by  an  increase  of 
the  connective  tissue.  Part  of  the  orbital  convolution  on  the 
right  side,  bordering  upon  the  Sylvian  fissure,  was  pushed  out 
into  a  protuberance,  resembling  an  epithelioma  in  shape,  and 
was  composed  of  the  same  firm  tissue  as  the  other  hardened 
parts.  The  hardening  excavating  process  had  extended 
slightly  to  the  tissue  covering  the  left  corpus  striatum,  but  it 
was  only  slightly  marked  as  compared  with  the  right  side. 
All  other  parts  of  the  brain,  the  cerebellum,  and  the  vessels, 
were  normal.  The  optic  nerves  were  normal  in  appearance,  not 
hardened.  The  growth  in  the  right  corpus  striatum  consisted  of 
numerous  small  granules  disposed  in  a  stroma  of  fine  reti- 
culated connective  tissue :  in  the  unstained  sections  the  structure 
could  with  difficulty  be  made  out ;  but  logwood  at  once 
differentiated  the  elements,  and  rendered  the  nature  of  the 
growth  evident.  The  general  appearance  of  the  tissue  was 
quite  that  of  a  hyperplasia  of  the  neuroglia  normally  existing 
between  the  nerve  elements,  and  differed  considerably  from 
that  presented  by  a  round  celled  sarcoma,  with  which  glioma 
is  frequently  considered  to  be  identical :  the  small  cells  of 
which  the  growth  was  mainly  composed  exactly  resembling 
the  granules  of  the  neuroglia,  and  being  much  less  in  size 
than  the  majority  of  the  cells  met  with  in  sarcomatous  tumours. 
The  enlarged  orbital  convolution  had  the  same  structure  as 
the  right  corpus  striatum. 

BemarJcs. — There  are  but  few  remarks  to  make  upon  this 
interesting  case ;  and  I  must  confess  to  having  been  in  consider- 
able doubt  as  to  the  nature  and  situation  of  the  cerebral  lesion. 

That  coarse  intra-cranial  disease  in  all  probability  existed 
was  clearly  shown  by  the  history  of  the  patient,  his  headache 
and  double  optic  neuritis,  though  the  presence  of  the  latter 
does  not  invariably  indicate  some  adventitious  intra-cranial  pro- 
duct, as  has  been  pointed  out  both  by  Drs.  Stephen  Mackenzie 1 
and  Hughlings-Jackson.2  Regarding  the  etiology  of  the  case, 
there  was  certainly  no  history  of  syphilis,  for  I  carefully  went 
into  the  question  ;  and  a  tubercular  tumour  appeared  to  me  to 
be  excluded  on  account  of  his  age,  the  absence  of  pyrexia 
and  of  symptoms  pointing  to  tuberculosis  of  other  organs ;  also 
the  long  duration  of  the  disease,  and  the  fact  of  his  gaining  in 
condition.  As  to  carcinoma  it  only  required  to  be  thought  of  to 
be  at  once  rejected.  On  the  whole  I  was  inclined  to  look 
upon  his  symptoms  as  probably  due  to  a  glioma,  or  to  some 

1  *  Brain,'  July  number,  1879,  p.  217. 

2  The  Koyal  Ophthalmic  Hospital  Report,  vol.  viii.,  pt.  iii.  p.  445. 


256  CLINICAL  CASES. 

sclerotic  process  ;  in  favour  of  glioma  was  the  long  duration  of 
the  disease,  and  his  maintaining  his  state  of  good  nutrition. 
With  regard  to  the  localization  of  the  disease,  it  was  impossible, 
in  my  opinion,  to  come  to  any  conclusion,  as  the  only  constant 
motor  symptom  was  the  fine  tremor  of  arms,  legs,  and  tongue, 
which  became  coarser  upon  an  attempt  at  voluntary  move- 
ment, and  in  that  respect  resembling  the  tremor  of  multiple 
sclerosis,  but  differing  from  it  in  the  smallness  of  the  oscilla- 
tion, and,  with  the  exception  of  the  tongue,  as  a  rule  not  ex- 
tending to  the  head.  It  certainly  appears  to  be  a  remarkable 
fact,  considering  the  position  of  the  growth,  more  especially  its 
infiltrating  the  right  corpus  striatum,  that  he  had  no  hemiplegia, 
and,  excepting  on  the  occasion  when  I  last  examined  him 
(April  11th,  1879),  any  diminished  power  in  the  grasp  of  the 
left  hand,  but  it  only  confirms  Obernier's 1  statement,  that  the 
intensity  of  the  symptoms  produced  by  a  cerebral  tumour  are 
in  direct  ratio  with  the  rapidity  of  its  growth,  and  vary  greatly 
according  to  individual  irritability;  also  it  is  impossible  to 
compare  slow  growing  tumours,  which  may  press  aside  without 
destroying  nerve  paths,  with  those  lesions,  which  in  their  rapid 
march  destroy  whole  territories  of  the  central  nervous  system. 
The  mental  symptoms  exhibited  by  this  patient  were  partly 
due,  I  imagine,  to  the  changes  we  found  in  the  profrontal  lobes 
(orbital  convolution) ;  as  injuries,  and  diseases  of  that  region, 
according  to  Dr.  Terrier,2  are  not  followed  by  paralysis  of 
motion  or  sensation,  but  by  psychical  disturbances  of  various 
kinds.  The  partial  bilateral  anosmia,  I  believe,  was  simply 
the  result  of  brain  squeezing. 

1  'Cyclopaedia  of  Medicine,'  Von  Ziemssen,  vol.  xii.  p.  241,  243,  2G4. 

2  Dr.  Ferrier,  '  Gulstonian  Lectures  on  the  Localization  of  Cerebral  Diseases.' . 


(Read  before  the  Bath  Pathological  and  Clinical  Society.) 


Abstracts  of  grittslj  anfr  Jfisragn  Jfountals. 
Method  of  Preserving  the  Brain. — Professor  Carlo  Giaco- 

mini  of  Turin  has  lately  described  a  process  for  the  preservation 
of  the  Brain  and  Nerves  which  promises  to  be  of  great  utility  to 
the  anatomist  and  pathologist.  The  description  of  the  process  was 
communicated  to  the  Eoyal  Academy  of  Medicine  of  Turin  on  the 
7th  June  1879,  and  as  I  lately  had  an  opportunity  of  seeing  the 
results  of  the  method  employed,  and  was  much  impressed  with  its 
success,  I  think  some  account  of  it  may  be  interesting  to  the 
readers  of  this  journal. 

After  referring  to  the  various  methods  previously  proposed,  such 
as,  1,  the  plan  of  Broca  (1860),  of  hardening  in  nitric  acid  diluted 
with  nine  parts  of  water,  and  subsequent  desiccation ;  2,  that  of 
Frederig  of  Ghent,  modified  by  Duval  of  Paris,  of  successive  immer- 
sion in  dilute  nitric  acid,  chromate  of  potash,  alcohol  and  liquid 
paraffin ;  and  3,  the  plan  of  l'Ore  of  Bordeaux,  by  immersion  in 
alcohol,  subjection  to  a  temperature  of  45°  C.  for  15  or  20  hours, 
varnishing  with  gum  elastic,  and  finally  electroplating,  and  stating 
the  insufficiency  of  them  all  for  the  convenient  preservation  and 
subsequent  examination  of  the  brain,  Professor  Giacomini  explains 
the  manner  in  which,  from  a  knowledge  of  the  properties  of  glyce- 
rine, he  was  led  to  make  use  of  this  substance  for  the  preservation 
in  the  moist  state  of  brains  which  had  been  previously  indurated 
by  other  reagents. 

The  primary  induration  of  the  brain  may  be  effected  by  one  or 
other  of  several  reagents,  such  as  chloride  of  zinc,  chromate  of 
potash,  or  chromic  acid  solutions,  diluted  nitric  acid  or  alcohol, 
but  of  all  these  the  saturated  solution  of  chloride  of  zinc  appears 
for  several  reasons  to  be  the  best. 

The  newly  extracted  brain  is  placed  in  a  saturated  solution  of 
the  chloride  of  zinc,  with  the  membranes  still  adhering  to  it;  and 
after  an  immersion  for  about  48  hours  the  membranes  and  blood - 

VOL.  III.  S 


258  ABSTRACTS   OP   BRITISH 

vessels  may  with  ease  be  removed,  care  being  taken  to  preserve 
the  surface  as  entire  as  possible.  The  brain  at  first  naturally 
floats  in  the  solution,  so  that  it  must  be  turned  in  it  from  time  to 
time  till  the  whole  is  acted  upon,  and  from  the  increase  in  specific 
gravity  it  at  last  sinks  in  the  solution.  This  generally  occurs  after 
two  or  three  days'  further  immersion,  and  then  the  brain  is  to  be 
transferred  from  the  solution  to  alcohol  of  commerce.  By  this  part 
of  the  process  the  brain  loses  about  a  twentieth  or  twenty-fifth 
part  of  its  weight. 

Should  there  be  reason  to  believe  that  the  brain  has  suffered 
from  the  body  having  been  kept  too  long  after  death,  or  if  it  is 
wished  to  examine  it  in  situ,  the  induration  may  be  effected  by 
the  injection  of  600  grammes  of  the  saturated  chloride  of  zinc 
solution  into  the  internal  carotid  arteries. 

The  brain  when  transferred  to  the  alcohol  sinks  in  that  fluid, 
and  precautions  must  be  taken,  by  frequently  changing  its  position, 
to  prevent  any  alteration  of  form  by  pressure  against  the  sides  or 
bottom  of  the  vessel  in  which  it  is  laid.  After  remaining  ten  or 
twelve  days  in  the  alcohol,  the  brain  is  ready  to  be  transferred  to 
glycerine. 

For  this  purpose  white  or  colourless  fenicated  glycerine  (in  the 
proportion  of  1  to  100)  is  found  to  answer  best.  The  brain  must 
remain  in  the  glycerine  for  a  number  of  days  till  it  is  thoroughly 
impregnated  with  it,  when  it  will  be  found  to  have  regained  from 
5  to  6J  oz.  in  weight.  .  It  is  then  removed  from  the  glycerine, 
and  placed  in  any  convenient  situation,  to  allow  of  some  desiccation 
and  the  exudation  of  superfluous  fluid,  and  it  may  either  be  pre- 
served in  this  state,  or,  what  is  better,  it  may  be  covered  with  one 
or  more  layers  of  a  varnish  of  caoutchouc  or  marine  glue,  which, 
while  it  does  not  materially  alter  its  appearance  or  consistence, 
protects  the  surface  from  the  adhesion  of  dust  and  from  mechanical 
injury,  and  enables  the  preparation  to  be  handled  pretty  freely 
without  risk  of  breaking  the  surface.  The  final  varnishing  is  not 
however  necessary  if  the  preparations  are  otherwise  fully  pro- 
tected. 

Preparations  made  after  the  manner  now  described  may  be  kept 
for  years  in  close  glass  or  other  cases  without  change ;  and  such  is 
the  hygroscopic  property  of  the  glycerine  that  they  may  even  be 
left  exposed  for  a  considerable  time  in  ordinary  states  of  the  atmo- 
sphere without  undergoing  any  marked  alteration  in  weight  or 
appearance.  The  natural  form  and  colour  of  the  brain  are  in  great 
measure  maintained,  and  even   the  distinction    of  the   grey  and 


AND  FOEEIGN  JOURNALS.  259 

white  substance,  and  the  fibrous  character  of  the  latter  are  pre- 
served in  such  a  manner  that  thin  slices  can  be  made  and  dissec- 
tions of  the  preserved  brains,  much  in  the  same  way  as  in  a  fresh 
brain,  or  in  one  which  has  been  successfully  preserved  in  alcohol. 

It  is  true  the  microscopic  characters  of  minute  structure  are  not 
perfectly  preserved ;  but  this  could  not  have  been  expected  from 
any  other  methods  than  those  adopted  by  histologists  in  their 
improved  modern  processes.  But  for  the  conservation  of  series  of 
human  brains  and  those  of  animals  for  purposes  of  exhibition  and 
demonstration,  and  for  the  study  of  the  external  form  and  larger 
structure,  they  are  admirably  adapted  and  likely  to  prove  most 
valuable,  for  they  remain  to  some  extent  soft  and  pliable,  can  be 
handled  with  freedom,  and  may  be  dissected  or  examined  in  every 
way  that  may  be  desired. 

It  is  obvious  that  series  of  brains  so  preserved  are  remarkably 
well  adapted  for  the  study  of  the  comparative  anatomy  and 
homology  of  the  sulci  and  convolutions  both  in  man  and  animals, 
and  that  they  are  equally  well  suited  for  serving  as  records  of  the 
local  effects  of  pathological  changes  or  of  physiological  experi- 
ments. 

It  seems  unnecessary  to  follow  Professor  Giacomini  further  in 
his  description  of  the  varieties  in  his  method  of  preliminary 
hardening  by  other  reagents,  such  as  chromate  of  potash,  chromic 
acid,  &c,  as  that  by  means  of  the  chloride  of  zinc  appears  to  be  on 
the  whole  the  simplest  and  most  satisfactory. 

I  may  mention  further  that  in  the  Anatomical  Museum  of  the 
University  of  Turin  I  saw  also  with  Professor  Giacomini  elaborate 
isolated  dissections  of  the  whole  and  parts  of  the  central  nervous 
system,  in  connection  with  the  brain  and  spinal  marrow  and  with 
the  nerve  roots,  ganglia  and  plexuses,  and  the  anastomoses  and 
subdivision  of  branches  of  nerves  displayed  with  great  beauty  and 
accuracy,  and  all  preserved  in  the  moist  condition  after  the  same 
manner  as  the  brain  preparations,  and  exhibited  under  glass  covers  ; 
and  I  could  not  but  regard  these  as  most  useful  and  illustrative 
preparations  both  for  demonstration  and  study,  and  especially  as 
immeasurably  supeiior  to  the  older  preparations  of  the  same  kind 
in  the  dried  condition. 

Allen  Thomson. 


Krueg  on  the  Sulci  of  the  Zonoplacental  Mammalian 

Brain.     (Zeitsch.  fur  wis8enschaft.  Zoologie,  Bd.  23.     5  Plates.) — In 

S  2 


260  ABSTRACTS  OF  BRITISH 

this  memoir,  relating  chiefly  to  the  carnivora,  the  cerebral  sulci  are 
divided  into  three  groups. 

1.  Boundary-sulci  (Grenzfurchen)  (three  in  number)  which 
divide  the  hemisphere  into  histologically  different  regions,  and 
which  are  constant,  not  only  in  carnivora,  but  in  all  mammals, 
whether  smooth-brained  or  not. 

2.  Primary  sulci  (nine  in  number),  which  are  present  in  all 
species  of  carnivora  without  exception. 

3.  Secondary  sulci  (thirteen),  which  are  variously  arranged  in 
different  groups,  and  in  some  are  accessory  or  wanting  altogether. 
The  individual  families  of  the  carnivora  may  be  identified  with 
tolerable  precision  by  the  presence  and  disposition  of  these  secon- 
dary sulci. 

Further,  Krueg  indicates  homologies  between  the  sulci  of  the 
carnivora  and  ungulata,  and  renders  possible  a  thorough-going 
comparison  between  these  large  mammalian  groups.  The  work  is 
based  on  the  developmental  history  of  the  cat  and  dog.  In  addi- 
tion there  are  depicted  in  the  plates  the  brains  of  forty-seven 
different  species. 

H.  Obersteiner. 

Sur  le  Ddveloppement  du  Cerveau,  &c.   Ch.  Fere.    (Revue 

<T Anthropologic,  1879,  No.  3,  p.  661.) — The  author  gives  measure- 
ments of  certain  cranio-cerebral  relations  in  the  foetus  and  young 
child  (sixty  subjects),  with  especial  reference  to  the  relative  develop- 
ment of  cerebral  regions.  By  his  method  pegs  are  inserted  through 
the  fontanelles  to  assist  in  maintaining  the  normal  relations,  and 
the  parietals  are  reflected  outwards ;  the  falx  prevents  separation 
of  the  frontal  and  occipital,  and  so  maintains  the  ant.  post, 
diameter  of  the  brain,  while  the  bulging  lateral  diameter  can  be 
temporarily  restored  by  replacing  the  parietals.  Topography  is 
not  satisfactory  before  the  5th  foetal  month ;  at  the  6th,  the  fissure 
of  Bolando  is  unmistakable.  Contrary  to  what  has  been  affirmed 
this  fissure  is  throughout  posterior  to  the  coronal  suture,  and  con- 
verges to  it  from  above  downwards,  as  in  the  adult.  The  Sylvian 
fissure  passes  above  the  squamosal  bone,  and  the  parieto-occipital 
fissure  lies  in  front  of  the  lambda — while  in  adults  the  Sylvian  f. 
very  nearly  follows  the  ant.  sup.  half  of  the  squamous  border,  and 
the  lambda  is  nearly  always  on  a  level  with  the  parieto-occipital 
f.  From  these  relations  Fere  inclines  to  think  that  in  the  infantile 
brain  the  occipito-spheno-temporal  region,  "  the  sensory  and  vege- 
tative region  "  takes  precedence  in  growth,  and  is  relatively  more 


AND  FOREIGN  JOURNALS.  261 

voluminous  than  the  parieto-frontal  or  "psycho-motor  region;" 
that  is,  if  the  altered  relations  be  due  to  unequal  development  of 
the  contained  organ  and  not  of  the  containing  cavity — a  proviso 
that  diminishes  the  significance  of  the  observed  facts.  In  adult  life 
the  relations  between  sutures  and  fissures  continue  invariable ;  we 
have  seen  that  the  occipital  and  temporo-sphenoidal  lobes  appear 
to  maintain  the  same  limits  as  the  bones  they  lie  beneath,  and  we 
might  be  tempted  to  presume  a  parallelism  between  a  cerebral 
region  and  its  cranial  cover. 

Amidon  on  the  Effect  of  willed  Muscular  Movements 
on  the  Temperature  of  the  Head:  new  Study  of  Cerebral 
Cortical  Localization.  (New  York  Arch,  of  Med.,  April  1880.) — 
Lombard,  in  1867,  was  the  first  to  investigate  the  relation  between 
mental  effort  and  cerebral,  or  rather  suprajacent  cranial,  tempe- 
rature; he  employed  a  thermo-electric  apparatus  showing  varia- 
tions of  less  than  10100°  F.,  and  thus  demonstrated  a  rise  of  tem- 
perature in  the  head  and  fall  in  the  legs  with  various  attractions 
and  efforts  of  attention.  Since  that  time  the  subject  has  been 
pursued,  both  as  regards  parts  of  the  brain  or  suprajacent  parts  of 
the  cranium,  by  a  series  of  observers,  Schiff,  Broca,  Gray,  Mara- 
gliano,  Seguin,  &c.  v 

The  present  paper,  to  which  a  prize  has  been  awarded  by  the 
New  York  College  of  Surgeons  and  Physicians,  is  an  outcome  of 
the  supposition  that  with  the  exercise  of  a  peripheral  group  of 
muscles,  heat  generated  in  cortical  centres  might  manifest  itself  to 
surface  thermometers  placed  on  the  scalp ;  the  writer  relates  the 
striking  result  of  a  preliminary  experiment  to  test  this  view : 
"  Surface  thermometers  were  arranged  in  a  strap  passing  across 
the  vertex,  where  the  centre  of  the  arm  was  thought  to  be.  After 
15  m.  the  temperatures  were  recorded;  violent  flexion  and  exten- 
sion of  the  forearm  was  then  kept  up  for  10  m. ;  the  temperatures 
now  taken  showed  that  a  rise  of  more  than  1°  F.  had  taken  place 
over  the  centre  for  the  arm  on  the  left  side  of  the  head  only."  The 
following  are  selected  from  the  detailed  accounts  of  further  re- 
searches on  the  "  thermic  foci,"  made  with  due  precautions  by  ap- 
plication of  numerous  surface  thermometers  to  the  scalp.  "  With 
movements  of  the  whole  upper  extremity  (flexion  and  extension 
of  the  fingers  and  forearm  and  some  rotation  of  the  shoulders)  a  rise 
of  temperature  varying  from  2*5°  to  2*75°  F.  was  caused  over  rather 
a  large  area,  extending  on  the  median  line  from  a  point  14  cm. 
behind  the  root  of  the  nose,  about  10  cm.  back  on  the  same  line, 


262  ABSTRACTS   OF   BRITISH 

laterally  about  9  cm.  from  the  median  line."  This  area  was 
further  subdivided  as  follows :  prolonged  and  repeated  contraction 
of  the  biceps  caused  a  rise  greatest  near  the  median  line,  about 

1 9  cm.  from  the  root  of  the  nose ;  by  further  approximation  of  the 
thermometers,  an  area  of  maximum  rise  was  defined  3  cm.  long, 
5  cm.  broad,  near  the  median  line  from  a  point  17  cm.  to  one 

20  cm.  behind  the  nose.  The  area  of  rise  caused  by  triceps  exer- 
tion is  placed  behind  the  preceding  area  of  biceps  exertion,  near 
the  median  line,  3*5  cm.  long,  and  6  cm.  broad.  That  caused 
by  flexion  and  extension  of  the  wrist  and  fingers  is  placed  at  about 
the  same  distance  from  the  nose  as  that  of  biceps  exertion,  but 
further  from  the  median  line;  in  the  diagram  its  upper  border 
considerably  overlaps  the  lower  border  of  the  biceps  and  triceps 
area.  This  and  other  overlappings  are  attributed  to  oblique  radia- 
tion of  heat,  and  to  insufficient  limitation  of  muscular  movement. 
The  anterior  part  of  the  above  area  adjacent  to  the  biceps  area  is 
assigned  to  flexors ;  the  posterior  part  adjacent  to  the  triceps  area, 
is  assigned  to  extensors  of  the  fingers  and  wrist.  General  move- 
ments of  the  shoulder-joint  and  scapula  caused  a  rise  over  a  large 
area,  anterior  to  the  area  for  the  arm,  approaching  near  to  the 
supraorbital  ridge  in  front,  extending  latei-ally  8  to  9  cm.  Of 
this  thermal  area,  5  cm.  long,  4  to  5  cm.  broad,  extending  from 
the  biceps  area  to  within  13  cm.  of  the  nose,  is  attributed  to  the 
deltoid  exertion.  To  the  trapezius  and  levator  anguli  scapulae  is 
attributed  an  area  extending  along  the  median  line,  anterior  to  the 
deltoid  area,  to  within  5  to  6  cm.  of  the  nose,  and  being  6  to 
6*5  cm.  broad.  By  exercise  of  the  pectoralis  an  area  of  increased 
temperature  was  obtained  external  to  the  preceding,  opposite  to  a 
point  on  the  median  line  14  cm.  from  the  nose,  being  3  cm. 
long,  3  to  4  cm.  broad.  An  area  of  equal  size  behind  the  pre- 
ceding is  allotted  to  the  latissimus  dorsi.  Movements  of  the  head 
and  neck  were  found  to  cause  rise  of  temperature  over  a  con- 
siderable area  in  the  lateral  frontal  region  external  to  the  shoulder 
region.  General  movements  of  the  leg  and  thigh  caused  an  eleva- 
tion of  temperature  over  an  indefinite  area  lying  behind  that  of 
the  upper  extremity.  Flexion  of  the  foot  with  extension  of  the 
toes  gave  a  rise  in  an  area  (anterior  tibial)  4  cm.  long  5  cm. 
wide,  lying  next  the  median  and  posterior  to  the  area  of  the  triceps 
brachii.  Contraction  of  the  calf-muscles  caused  rise  in  an  area 
behind  the  preceding  2*5  long  by  5  cm.  broad.  "  Contraction  of 
the  quadriceps  extensor  femoris  developed  the  rather  startling  fact 
that  activity  of  this  muscle  caused  a  rise  of  tomperature  over  a 


AND  FOREIGN   JOURNALS.  263 

correspondingly  large  area  of  the  posterior  part  of  the  head."  It 
occupied  a  position  next  the  median  line  of  the  head,  extending 
from  the  posterior  boundary  of  the  calf  area  30  cm.  behind  the 
nose,  very  nearly  to  the  occipital  protuberance,  38  cm.  behind 
the  nose,  averaging  5  cm.  in  breadth.  "  Some  rises  in  this  area 
amounted  to  2'75°  F."  Other  areae,  external  to  the  preceding,  are 
distributed  to  flexors  of  the  thigh,  abdominal  muscles,  erector 
spinae.  The  thermal  areae  of  facial  and  lingual  muscles  are  indi- 
vidually defined  in  the  lateral  region  of  the  skull  external  to  the 
centres  of  the  upper  extremity,  8  to  10  cm.  above  the  external 
auditory  meatus. 

In  conclusion  the  writer  draws  attention  to  the  striking  corre- 
spondence between  these  thermal  areae  on  the  scalp  and  Terrier's 
psychomotor  areae  of  the  cortex,  and  asks  whether  some  of  the 
elevations  referred  by  Lombard  to  mental  states  are  not  largely 
due  to  muscular  action.  He  adds  to  Ferrier's  chart  by  locating 
psychomotor  centres  on  the  frontal  or  psychical  lobes,  and  remarks 
with  some  justice  that  the  usual  routine  examination  of  a  patient 
is  not  likely  to  reveal  losses  of  power  limited  to  muscles  like  the 
trapezius,  deltoid,  pectoralis,  &c. ;  only  when  these  symptoms  have 
been  properly  looked  for  and  not  found,  the  belief  in  destructive 
frontal  lesions  without  paralysis  will  be  legitimated. 

A.  Waller. 

Visceral  Neurology — Bespiration. — Some  of  the  most  inter- 
esting contributions  to  visceral  neurology  during  the  last  six 
months  have  been  made  in  the  nervous  mechanism  of  respiration. 
Langendorff  of  Konigsberg  has  published  several  important  obser- 
vations with  respect  to  the  situation  and  relations  of  the  so-called 
respiratory  centre.  In  the  first  place  he  has  confirmed  the  view  of 
Longet,  Volkmann,  and  Schiff,  that  the  respiratory  centre  in  the 
medulla  is  double,  either  centre  corresponding  with  its  own  half 
of  the  body,  inasmuch  as  longitudinal  division  of  the  medulla  in 
the  middle  line  does  not  interfere  with  the  rate  or  regularity  of 
the  respiratory  movements.  A  connection  between  the  two  centres 
must  exist,  however,  for  it  is  a  familiar  fact  that,  when  both  vagi 
are  cut,  the  respiratory  movements  continue  to  be  synchronous. 
Langendorff's  new  observation  is  that  when  this  direct  connection 
between  the  two  centres  has  been  severed  by  longitudinal  incision, 
section  of  either  vagus  causes  disturbance  of  the  respiratory  move- 
ments on  the  corresponding  side  only,  the  rhythm  becoming,  as 


264  ABSTRACTS   OF   BRITISH 

usual,  slower;  whilst  simultaneous  section  of  both  vagi  leads 
similar  disturbance  on  both  sides,  the  rhythm  on  the  two  sides  of 
the  chest  being  different  in  time  and  frequency.  Irritation  of  the 
central  end  of  the  divided  vagus  of  either  side,  either  directly,  or 
indirectly  (e.  g.  through  the  trigeminus  in  the  nose)  leads  to 
arrest  of  the  movements  of  the  diaphragm  on  the  corresponding 
side  only.  It  thus  appears  that  either  vagus  is  connected  with 
the  respiratory  centre  of  its  own  side,  and  that  this,  again,  inner- 
vates its  own  half  of  the  diaphragm;  and,  further,  that  beyond 
the  direct  local  connection  between  the  two  centres,  the  cause  of 
the  correspondence  in  the  rhythm  and  force  of  their  action  is  to  be 
found  in  their  relation  to  the  vagi.  (Centralbl.  f.  d.  tried.  Wiss.  1879, 
p.  913.) 

'  In  a  more  recent  paper  {ibidem,  1880,  p.  97)  Langendorff  gives 
an  account  of  certain  experiments  which  appear  to  prove  the 
existence  of  "  respiratory  centres  "  in  the  spinal  cord.  Both  after 
section  of  the  cord  below  the  medulla,  and  after  ligature  of  the 
cranial  arteries  (in  the  rabbit),  he  observed  whole  series  of  com- 
plete respiratory  movements.  The  previous  administration  of 
moderate  doses  of  strychnia  remarkably  increased  the  distinctness 
of  these  movements,  which  were  not  only  spontaneous  for  a  time, 
but  also  induced  reflexly  by  stimulation  of  different  sensory  nerves. 
Langendorff  suggests  in  explanation  of  these  results  that  the  auto- 
matic respiratory  centres  are  situated  in  the  cord,  and  that  the 
medulla  exercises  only  the  function  of  a  regulating  apparatus,  the 
importance  of  which  in  normal  respiration  must  not  be  under- 
rated. 

Whilst  the  limits  of  the  "  respiratory  centre "  have  thus  been 
extended  downwards,  Christiani  announces  {ibidem,  1880,  p.  273) 
that  he  has  discovered  a  respiratory  centre  of  limited  extent  in 
the  floor  of  the  third  ventricle  and  in  the  substance  of  the  optic 
thalami,  beside  the  corpora  quadrigemina.  Irritation  of  this  spot, 
directly  or  indirectly,  causes  respiratory  arrest  in  inspiration. 
This  observation  is  of  great  interest  in  connection  with  that  of 
Drs.  Martin  and  Booker,  which  was  recorded  by  us  in  Vol.  I.  of 
«  Brain,'  p.  585. 

The  influence  of  the  vagus  on  respiration  has  long  been  familiar 
to  physiologists ;  and  attention  has  more  recently  been  directed  to 
the  character  and  origin  of  the  impressions  which  are  being  con- 
stantly transmitted  upwards  through  it  to  the  respiratory  centre. 
The  Selbsteurung  theory  of  Breuer, — that  the  conditions  of  dilatation 
and   contraction  of  the  lungs,  at  the  end  of  inspiration  and  of 


AND  FOEEIGN  JOUKNALS.  265 

expiration  respectively,  are  stimulants  to  the  immediately  following 
acts,  that  is,  to  expiration  and  inspiration  respectively ;  and  that 
the  impressions  of  the  conditions  of  distension  and  contraction  are 
conveyed  upwards  by  the  vagus  to  the  respiratory  centre — has  been 
steadily  receiving  support  from  recent  observations.  LangendorfF 
(De  Bois  Keymond's  Archiv  f.  Anat.  u.  Physiol.  1879,  Supplement- 
Band,  p.  48)  has  discovered  that  when  artificial  inflation  of  the 
lungs  is  carefully  carried  out  in  non-narcotised  animals,  expiration 
is  induced ;  and  that  dilatation  of  the  lungs  acts  therefore  as  an 
expiratory  stimulant.  The  experimenters  who  previously  failed  to 
obtain  this  result  operated  on  chloralised  animals.  That  the  move- 
ments following  inflation  of  the  lungs  were  not  the  result  of  simple 
elastic  recoil  was  proved  by  the  fact  that  they  were  arrested  by 
section  of  the  vagi.  On  the  other  hand,  Gad  of  Wiirtzburg,  experi- 
menting differently,  doubts  the  truth  of  Breuer's  beautiful  theory 
as  far  as  it  applies  to  the  inspiratory  effect  of  expiration,  inasmuch 
as  interruption  of  the  vagus  does  not  increase  but  diminish  the 
length  of  the  expiratory  act.  Whilst  making  these  experiments, 
Gad  succeeded  in  finding  a  non-irritant  means  of  suddenly  paralysing 
the  vagus,  and  thus  of  avoiding  the  stimulant  effects  of  section, 
which  always  follow  for  a  short  time  and  disturb  the  results. 
This  non-irritant  interruption  he  found  in  freezing,  which  appears 
to  cause  no  irritant  effect  whatever.  {Ibidem,  1880,  i.  and  ii. 
p.l.) 

Von  Anrep  (Pfluger's  Archiv,  xxi.  (1  and  2),  p.  78,  has  shown 
that  the  vagus  of  the  cat  possesses  its  familiar  influence  on  respira- 
tion from  the  time  of  the  birth  of  the  animal. 

The  Heart. — The  author  just  referred  to,  in  the  same  paper,  con- 
firms to  a  great  extent  the  observation  of  Soltmann  that  in  kittens 
a  few  hours  old  it  is  impossible  to  stop  either  the  whole  heart  or 
any  of  its  parts  by  irritation  of  the  vagus  with  moderate  currents. 
In  the  course  of  two  to  seven  days  powerful  currents  arrest  the 
ventricles  but  not  the  auricles.  After  seven  to  fourteen  days  the 
inhibitory  centres  are  in  a  condition  to  cause  stand -still  of  the 
whole  heart.  During  the  first  days  of  life  section  of  the  vagus  in 
the  same  animal  has  no  effect  on  the  frequency  of  the  heart ;  and 
atropine  causes  no  acceleration. 

Three  of  the  most  prominent  symptoms  of  exophthalmic  goitre, 
namely,  cardiac  excitement,  exophthalmos,  and  swelling  of  the 
thyroid,  have  been  produced  together  experimentally  in  the  rabbit 
by  Filehne  (Centralbl.  f.  d.  med.  Wiss.  1880,  p.  192).  This  result 
was  obtained  by  section  of  the  restiform  bodies  in  their  anterior 


266  ABSTRACTS  OF   BRITISH 

fourth,  without  injury  of  the  under  surface  of  the  medulla.  The 
vagi  thereby  lost  their  control  of  the  heart ;  the  eyes  frequently 
became  prominent ;  and  the  thyroid  occasionally  swelled.  Only  in 
a  single  case,  however,  did  the  three  phenomena  occur  together. 

The  Uterus. — Eohrig,  experimenting  on.  rabbits,  has  located  the 
uterine  centre  in  the  cord  in  the  lumbar  and  lower  dorsal  region 
(Centralbl.  f.  d.  med.  Wiss.  1879,  p.  668).  He  has  also  found  that 
the  uterine  contractions  which  follow  diminution  of  oxygen  or 
excess  of  carbonic  acid  in  the  blood,  are  directly  referable  to  the 
condition  of  the  cord.  Anaesthetics  appear  to  reduce  the  excita- 
bility of  the  uterine  centre  in  the  cord,  whilst  strychnia,  picro- 
toxine,  nicotine,  coffee,  and  ammonia  excite  the  cord  and  the 
uterus.  Ammonia  alone  acts  upon  the  uterus  if  the  cord  be  pre- 
viously destroyed. 

J.  Mitchell  Bruce. 

Buzzard  on  certain  points  in   Tabes  Dorsalis  —  Three 

lectures  have  appeared  (Lancet,  January  10,  February  14,  May  1, 
1880). 

In  Lecture  I.,  after  sketching  the  anatomy  of  the  spinal  cord, 
attention  is  directed  to  the  degenerative  changes  observed  in  a 
case  of  transverse  myelitis  from  Pott's  disease.  These  extend 
upwards  in  the  form  of  fasciculated  sclerosis  in  the  posterior 
median  columns,  and  downwards  in  the  posterior  portion  of  each 
lateral  column.  A  condition  pathologically  similar  forms  the 
essential  change  in  tabes  dorsalis,  where  it  occupies  the  posterior 
root  zones.  The  secondary  degenerations  are  explained  by  Tiirck 
by  reference  to  Waller's  law  in  regard  to  degenerations  of  nerve- 
trunks  after  section.  Buzzard  thinks  that  there  is  clinical  evidence 
to  show  that  the  change  in  tabes  is  not  seldom  also  a  secondary 
affection,  and  that  it  commences  in  the  connective  tissue.  Du- 
chenne's  definition  of  the  disease  is  followed,  but  Komberg's  term, 
"  Tabes  dorsalis,"  is  preferred  to  "  Progressive  locomotor  ataxia." 
In  a  typical  case  exhibited,  two  symptoms  are  demonstrated  which 
are  not  included  in  Duchenne's  definition — the  absence  of  patellar 
tendon  reflex  and  inaction  or  sluggish  action  of  the  pupils  to  light,  whilst 
they  contract  normally  during  accommodation. 

In  Lecture  II.  attention  is  given  to  the  pains  which,  contrary  to 
the  experience  of  some  observers,  Buzzard  finds  present  in  tabes 
with  very  rare  exception  indeed.  Graphic  descriptions  by  patients 
illustrating  the  characteristics  of  these  pains  are  quoted  in  large 
numbers.      As  regards   their  frequency  Buzzard  has  analysed  a 


AND   FOREIGN   JOURNALS.  267 

collection  of  fifty- four  cases  of  tabes  occurring  in  his  own  practice, 
and  in  only  one  instance  were  the  pains  entirely  absent.  Erb's 
experience,  which  is  quoted,  goes  the  same  way,  and  out  of  a  total 
of  110  cases  analysed  by  these  observers,  pain  was  absent  in  only 
7  cases,  so  that,  as  far  as  these  figures  go,  pain  is  a  symptom  which 
occurs  in  tabes  in  the  proportion  of  nearly  94  per  cent,  of  the 
cases.  Buzzard  pictures,  as  very  characteristic  of  early  tabes,  a 
man  going  about  his  usual  occupation  with  activity,  and  presenting 
no  sign  of  ill-health,  but  liable  to  have,  from  time  to  time,  paroxysms 
of  horribly  severe  pains,  not  usually  limited  to  the  district  of  one  nerve, 
as  in  neuralgia,  but  commonly  attacking  more  than  one  locality. 
Hints  for  avoiding  errors  in  regard  to  the  examination  of  the 
patellar  tendon  reflex  are  given ;  and  it  is  pointed  out  that  it  is  the 
absence  of  this  reflex,  when  the  quadriceps  extensor  muscle  is  in 
a  normal  condition  as  regards  response  to  electric  currents  and 
blows,  which  is  the  striking  feature  in  Westphal's  test.  A  patient 
was  exhibited,  in  whom  this  reflex  was  discovered  to  be  absent  six 
months  after  the  first  symptoms  of  tabes.  As  regards  the  fre- 
quency of  the  symptom,  out  of  79  cases  of  tabes  in  which  this 
point  was  tested  (Erb  and  Buzzard"),  in  76  the  patellar  tendon 
reflex  was  absent.  In  two  out  of  the  three  exceptions  to  this  rule 
of  absence  there  was  no  ataxia  of  gait.  Buzzard  relates  a  case 
which  well  illustrates  the  value  of  the  symptom.  To  his  mind  it 
holds  the  same  rank  as  an  objective  symptom  of  tabes  as  is  occu- 
pied by  the  characteristic  pains  amongst  the  subjective  symptoms 
of  the  disease.  These  two  symptoms  are  the  most  constant  of  all, 
and  they  are  probably  the  earliest.  Buzzard  believes  that  if  a 
patient  presents  both,  no  other  is  needed  to  form  a  diagnosis  of 
tabes  dorsalis. 

Lecture  III.  deals  with  the  oculo-pupillary  symptom  first  dwelt 
upon  by  Argyll  Kobertson,  and  recently  investigated  extensively 
by  Ch.  Vincent  in  Charcot's  clinique.  Out  of  51  tabetic  patients 
in  only  4  the  pupils  reacted  normally.  In  7  there  was  complete 
immobility  of  the  pupils  (usually  combined  with  amaurosis),  and 
in  40  the  pupils  did  not  react,  or  reacted  imperfectly,  to  light ;  but 
contracted  during  accommodation.  Buzzard  has  devised  a  very 
convenient  method  of  testing  the  pupils  for  this  condition.  The 
patient  is  directed  to  look  over  the  observer's  shoulder  at  a  distant 
object.  A  strong  light  is  then  cast  upon  the  eye  with  the  ophthal- 
moscopic mirror,  and  the  pupil  watched  through  a  convex  lens  of 
about  No.  12  behind  it.  If  the  pupil  does  not  contract,  the  patient 
is  next  told  to  look  alternately  at  the  distant  object  and  at  one 


268  ABSTRACTS  OF   BRITISH 

within  ten  inches  or  so  of  his  eye.  Uniform  illumination  should 
be  maintained,  and  the  diameter  of  the  pupil  watched  as  the  gaze 
is  shifted.  B.  suggests  that  a  very  interesting  generalization  is 
derivable  from  this  symptom.  It  is,  he  points  out,  the  reflex 
movement  of  the  iris  which  is  abolished  or  greatly  affected  in 
tabes — the  voluntary  movement,  that  which  occurs  during  accom- 
modation of  the  eye  for  near  objects,  is  preserved.  This  is  pre- 
cisely analogous  to  what  happens  with  regard  to  the  patellar 
tendon  reflex,  and  the  circumstance  lends,  he  thinks,  additional 
support  to  Pierret's  view,  that  tabes  essentially  attacks  the  sensory 
side  of  the  cerebro-spinal  nervous  system — reflex  movements  being 
excited  by  impulses  travelling  along  afferent  (sensory)  nerves. 

Next  comes  an  investigation  of  the  pains  in  the  head  in  tabes ;  and 
it  is  shown  that  these  are  very  common,  and  that  their  occurrence  is 
readily  explained  (as  Pierret  describes),  by  imagining  a  continuation 
upwards  of  the  sclerosis  of  the  posterior  root-zones  (the  essential 
change  in  tabes)  to  the  descending  root  of  the  fifth  nerve,  which  in 
the  lower  portion  of  the  medulla  oblongata  forms  a  crescent  enclosing 
the  gelatinous  substance  of  the  posterior  horn.  An  original  and 
very  clear  diagram  shows  why  lightning  pains  should  be  expected  to 
occur  in  the  region  of  the  occipital  and  trigeminal  nerves.  Buzzard 
suggests  that  certain  cases  of  supposed  obstinate  neuralgia  of  the 
fifth  may  really  depend  upon  sclerosis,  which  is  limited  perhaps 
to  this  root.  He  describes  some  important  diagnostic  differences 
between  cranial  neuralgia  and  these  cephalic  pains  of  tabes.  A 
patient  was  shown  who  had  applied  on  account  of  excruciating 
pains  in  the  head.  He  was  blind.  The  symptoms  suggested  intra- 
cranial tumour,  but  the  patellar  tendon  reflex  was  absent,  and 
investigation  showed  that  the  case  was  one  of  tabes  with  cephalic 
pains  and  sclerosal  atrophy  of  the  optic  discs.  Another,  who  had 
optic  atrophy  and  the  Argyll  Eobertson  pupil,  was  reported  to 
stagger  occasionally,  but  had  nothing  else  except  absence  of  patel- 
lar tendon  reflex.  The  lecturer  referred  to  another  he  had  seen  in 
private,  in  whom  the  absence  of  the  reflex  was  the  only  symptom 
in  addition  to  optic  atrophy.  There  could  be  no  doubt,  he  thought, 
that  these  were  cases  of  tabes  dorsalis  as  yet  in  a  restricted  form. 

J.  Hughlings-Jackson. 

Abstracts  of  the  Gulstonian  Lectures  on  Epilepsy.  By 
W.  E.  Gowers,  M.D.,  F.B.C.P. 

Lecture  I.  The  subject  selected  for  the  lectures  was  a  study  of 
the  history  of  chronic  idiopathic  convulsive  diseases,  founded  on  a 


AND  FOREIGN  JOURNALS.  269 

numerical  analysis  of  a  series  of  cases  which  had  been  under  the 
lecturer's  care,  chiefly  at  the  National  Hospital  for  the  Paralysed 
and  Epileptic.  All  cases  had  been  excluded  in  which  there  was 
any  reason  to  suspect  organic  brain  disease,  and  all  cases  of  simple 
hysterical  fits  without  distinct  loss  of  consciousness.  The  cases  in- 
cluded consisted  of  epilepsy  proper,  epileptiform  convulsions,  not  due 
to  organic  brain  disease,  and  cases  such  as  are  commonly  designated 
hystero-epilepsy,  which  present,  with  loss  of  consciousness,  convul- 
sive movements  consisting  of  more  or  less  co-ordinated  spasm,  but 
often  combined  with  distinct  epileptic  symptoms.  Care  was  taken 
however  to  distinguish  as  far  as  possible  the  degree  in  which  the 
various  conclusions  applied  to  one  or  the  other  class.  The  hystero- 
epileptic  cases  constituted  18-J  per  cent,  of  the  whole  (185  cases 
out  of  1000  on  which  an  accurate  opinion  could  be  formed  of  the 
character  of  the  attacks). 

The  first  lecture  was  devoted  to  the  subject  of  causation.  Ee- 
garding  the  influence  of  sex,  the  proportion  of  1450  cases  was  found 
to  be  53*4  per  cent,  females,  46'6  per  cent,  males,  or  nearly  as  6  to 
5.  The  excess  of  females  was  smaller,  though  still  marked  (52  per 
cent.),  in  the  cases  of  pure  epilepsy  taken  separately.  Of  the 
hystero-epileptics,  females  constituted  two-thirds.  The  investigation 
of  heredity  was  directed  to  the  existence  of  epilepsy,  insanity, 
chorea,  hysteria,  and  certain  forms  of  paralysis — paraplegia  and 
infantile  paralysis.  Hemiplegia  was  excluded  as  primary  vascular. 
The  cases  of  hysteria  or  paratysis  in  relatives  were  insignificant 
in  numbers.  Inheritance  was  traceable  in  36  per  cent.  (452  of 
1250  cases),  and  in  the  same  proportion  in  the  epileptics  and  in 
hystero-epileptics.  Heredity  influences  sex  ;  in  the  cases  with  in- 
heritance the  females  were  5  per  cent,  more  numerous  than  in 
those  without  inheritance.  The  heredity  was  on  the  father's  side 
in  35  per  cent.,  and  from  the  mother's  side  in  39  per  cent.,  from 
both  in  5  per  cent.,  and  only  brothers  or  sisters  suffered  in  15  per 
cent.  The  side  of  the  inheritance  influences  the  sex  of  the  sufferers. 
The  percentage  of  males  affected  was  22  per  cent,  greater  when 
the  disease  was  inherited  from  the  father's  side  than  when  from 
the  mother's.  The  reason  why  the  females  are  in  such  excess  in 
the  inherited  cases  is  because  the  inheritance  is  more  frequently 
maternal,  and  then  more  girls  suffer  than  boys.  A  family  his- 
tory of  epilepsy  was  obtained  in  three-quarters  of  the  inherited 
cases.  In  half  (240  cases)  it  existed  alone ;  in  54,  combined  with 
insanity.  Insanity  occurred  in  a  third  (157  cases),  and  existed 
alone  in  the  majority.     Chorea  occurred  in  relatives  of  35  cases. 


270  ABSTRACTS  OP    BRITISH 

The  mother  is  herself  less  frequently  diseased  than  the  father :  she 
is  as  frequently  epileptic  as  the  father,  but  is  much  less  frequently 
insane.  A  case  was  related  in  which  14  members  of  the  family 
suffered  from  epilepsy. 

Phthisis  has  been  supposod  by  some  to  predispose  to  epilepsy, 
and  is  certainly  frequent  in  the  family  histories  of  epileptics,  but 
others  believe  not  more  so  than  is  explained  by  its  commonness. 
Individual  cases  suggest  ah  influence,  but  statistics  scarcely  support 
it.  A  history  of  phthisis,  in  some  relative,  was  obtained  in  39  per 
cent,  only,  of  300  cases.  The  proportion  of  phthisis  is  just  the 
same  in  those  with  and  those  without  neurotic  heredity,  and  the 
percentage  of  neurotic  heredity  is  nearly  the  same  in  those  with 
and  those  without  a  history  of  phthisis.  Signs  of  inherited  syphilis 
were  present  in  8  cases  of  apparently  idiopathic  epilepsy,  and  in  6 
of  these  the  fits  began  after  childhood. 

The  influence  of  age  was  ascertained  from  1450  cases,  and  the 
percentage  commencing  in  decennial  periods  was — under  ten,  29  ; 
between  ten  and  twenty,  46 ;  between  twenty  and  thirty,  15*7 ; 
between  thirty  and  forty,  6  ;  between  forty  and  fifty,  2 ;  and  over 
fifty,  3;  12^  per  cent,  of  the  total  commenced  in  the  first  three 
years  of  life,  and  5%  per  cent,  in  the  first  year.  The  number, 
commencing  per  annum,  fell  to  the  sixth  year,  and  then  rose  to 
a  maximum  in  the  sixteenth  and  seventeenth  years,  to  fall  rapidly 
after  that  age.  The  latest  case  was  one  which  commenced  at  71. 
Sex  is  influenced  by  age.  In  the  cases  commencing  under  ten 
years,  the  females  exceeded  the  males  by  6  per  cent.;  in  those 
between  ten  and  twenty,  by  18  per  cent. ;  between  twenty  aud 
thirty,  by  12  per  cent.  After  this  the  relation  is  reversed.  The 
males  exceeded  the  females  between  thirty  and  forty  years  by  16 
per  cent. ;  between  forty  and  fifty  by  36  per  cent. ;  between  fifty 
and  sixty  by  40  per  cent.  Over  fifty -five  males  only  suffered. 
At  each  maximum  period,  both  at  infancy  and  puberty,  the  excess 
of  females  was  very  great. 

The  influence  of  heredity  on  age  was  ascertained  from  1120 
cases,  and  found  to  be  much  more  uniform  than  current  statements 
suggest.  Of  cases  commencing  under  twenty  (844  in  number), 
38  per  cent,  presented  heredity.  Of  those  between  twenty  and 
forty,  34  per  cent. ;  and  of  those  over  forty,  27  per  cent.  The  case 
which  commenced  at  seventy-one  presented  heredity — his  father 
having  been  epileptic.  In  the  first  twenty  years  of  life  the 
disease  is  hereditary  in  a  larger  proportion  of  females  than 
of  males ;  between  thirty  and  forty,  by  more  males  than  females. 


AND   FOREIGN  JOURNALS.  271 

How  far  do  age  and  sex  influence  the  occurrence  of  the  hystero- 
epileptic  or  co-ordinated  forms  of  convulsion  ?  Of  1000  cases,  this 
form  constituted,  in  those  commencing  under  ten,  15  per  cent,  of 
the  male  and  18  per  cent,  of  the  female  cases.  In  those  com- 
mencing between  ten  and  twenty,  it  formed  14  per  cent,  of  the 
male  and  26  per  cent,  of  the  female  cases.  Between  twenty  and 
thirty  the  percentage  of  male  hystero-epileptics  is  still  14,  of 
females  21.  Between  thirty  and  forty  the  male  cases  fall  to  12  per 
cent.,  the  females  rise  to  26.  In  cases  commencing  over  forty, 
this  form  is  practically  unknown  in  either  sex.  It  is  remarkable, 
however,  that  up  to  the  fourth  decade  of  life,  one-third  of  the 
cases  presenting  hystero-epileptic  phenomena  occurred  in  males. 

In  considering  the  influence  of  exciting  causes,  the  first  point 
deserving  attention  is  the  cause  of  the  large  number  of  cases  (180) 
which  begin  in  the  first  three  years  of  life.  In  one-third  no 
causal  information  could  be  obtained.  Of  the  remainder,  in  three 
quarters,  the  first  fits  occurred  during  dentition,  and  were  referred 
to  it.  The  percentage  of  neurotic  heredity  was  34,  rather  less 
than  for  the  whole  of  life.  If  we  ascribe  to  dentition  convulsions 
the  same  proportion  of  the  cases  respecting  which  nothing  was 
known,  7  per  cent,  of  the  whole  become  attributable  to  this  cause. 
Teething  convulsions  are,  however,  well  known  to  be  usually 
associated  with,  and  in  large  part  the  result  of,  the  state  of  defec- 
tive development  which  we  call  rickets,  and  the  details  of  many 
of  these  cases  supplied  abundant  confirmation  of  this.  But  in  27 
other  cases,  which  commenced  after  infancy,  there  had  been  severe 
dentition  convulsions.  If  we  attribute  a  predisposing  influence  to 
the  early  fits  in  these  cases,  we  have  a  total  of  nearly  10  per  cent, 
of  the  whole,  in  the  causation  of  which  rickets  probably  took  part. 
This  suggests  that  a  considerable  number  of  cases  of  epilepsy  may 
be  prevented  by  attention  to  the  hygiene  and  diet  of  infants. 

Excluding  these  cases,  a  probable  exciting  cause  was  ascertained 
in  438  out  of  1150  cases,  or  37  per  cent.,  and  was  described  in  males 
(44  per  cent.)  more  frequently  than  in  females  (31  per  cent.),  and 
the  smaller  proportion  in  the  latter  was  chiefly  due  to  the  large 
proportion  of  cases  in  women  between  ten  and  forty  years  for 
which  no  exciting  cause  could  be  traced.  In  males  the  proportion 
presented  but  little  variation  in  the  different  periods,  increasing, 
however,  late  in  life. 

Of  the  cases  presenting  an  exciting  cause,  more  than  a  third 
(157  cases)  were  attributed  to  psychical  influences,  aud  of  these 
fright  caused  no  less  than  119.     It  is  effective  chiefly  in  early  life 


272  ABSTRACTS  OF   BRITISH 

— -only  3  commenced  after  thirty,  and  100  commenced  under  twenty. 
The  age  at  which  the  two  sexes  suffered  accords  with  their  known 
emotionality — they  were  affected  equally  under  ten.  The  males 
were  to  the  females  between  ten  and  thirty  as  3  to  4;  between 
twenty  and  thirty,  as  3  to  13  ;  and  over  thirty,  the  only  cases  were 
in  women.  The  influence  of  this  cause  is  readily  intelligible  when 
the  motor  and  visceral  disturbance  which  alarm  causes  is  con- 
sidered. In  one-third  the  first  fit  occurred  immediately  after  the 
fright,  in  the  others  an  interval  elapsed.  Two- thirds  of  the  cases 
due  to  this  cause  were  epileptic,  one-third  hystero-epileptic.  The 
form  of  the  fits  is  influenced  by  the  interval  after  the  fright — the 
shorter  this  is,  the  larger  the  proportion  of  cases  of  hystero-epilepsy. 
Other  forms  of  mental  excitement  caused  the  first  fit  in  19  cases. 
Anxiety  was  the  cause  in  29  cases,  in  which  males  preponderated. 

Sixty-five  cases  were  apparently  excited  by  blows  and  falls  on  the 
head.  This  cause  affects  the  sexes  equally  under  ten,  but  females  after 
this  date  in  gradually  decreasing  numbers.  In  two-thirds  of  the 
cases  the  injury  was  a  fall,  in  one-third  a  blow.  In  one-fifth  the 
first  fit  occurred  instantly,  in  the  others  an  interval  elapsed.  Expo- 
sure to  the  sun  was  the  alleged  cause  in  a  considerable  number  of 
cases,  and  seemed  probable  in  27 — 20  males  and  7  females.  The 
males  were  distributed  equally  through  life,  most  of  the  female  cases 
commenced  in  childhood.  The  form  of  convulsion  was  almost 
always  pure  epilepsy.  In  10  there  was  a  distinct  attack  of  sunstroke. 
An  acute  disease  was  the  cause  of  the  first  fit  in  37  cases,  14 
males  and  23  females.  In  9  it  was  measles,  and  in  19  scarlet  fever. 
In  many  of  the  latter  cases  there  was  no  dropsy  or  ear-disease ;  the 
first  fit  occurred  during  the  height  of  the  fever,  or  during  con- 
valescence, and  was  apparently  due  to  the  effect  of  the  scarlet  fever 
poison  on  the  nerve-centres.  In  9  cases  the  first  fit  was  after 
immersion  in  the  water,  in  6  it  was  ascribed  to  digestive  derange- 
ment, and  in  6  to  intestinal  worms,  the  attacks  continuing  after 
the  worms  had  been  expelled.  Chronic  alcoholism  caused  13  cases. 
Six  patients  were  the  subjects  of  chronic  lead-poisoning.  In  2  of 
these  there  was  renal  disease,  in  1  fits,  existing  before,  were  inten- 
sified by  the  plumbism,  in  the  remaining  3  the  cases  appeared  to  be 
saturnine  epilepsy,  chronic,  resembling  ordinary  epilepsy.  In  2 
other  cases  chronic  renal  disease  was  the  only  discoverable  cause  of 
chronic  epileptiform  convulsions,  without  other  signs  of  uraemia. 
Both  lead  and  renal  disease  occasionally  cause  mental  derangement. 
One  case  was  apparently  due  to  working  in  a  tobacco  factory ; 
one  commenced  after  the  inhalation  of  chloroform,   and   in  one, 


AND   FOKEIGN  JOURNALS.  273 

attacks  which  had  ceased  for  many  years,  recommenced  after  the 
inhalation  of  nitrous  oxide. 

Of  sexual  processes,  retarded  or  absent  menstruation  coincided 
with  the  first  fit  in  a  large  number  of  cases,  in  girls  at  puberty,  but 
the  causal  relation  between  the  two  was  difficult  to  ascertain. 
Masturbation  is  frequent  in  epileptic  boys,  but  was  certainly  the 
cause  of  the  fits  in  only  a  few  cases. 

The  heart  was  not  examined  in  all  cases,  but  in  93  abnormality 
was  found;  frequency  of  action  in  8,  irregularity  in  9,  reduplica- 
tion of  the  first  sound  in  13  (all  young).  In  30  cases  there  was 
valvular  disease;  mitral  regurgitation  in  20,  mitral  constriction 
in  7,  aortic  regurgitation  in  3,  aortic  constriction  in  1.  There 
was  dilatation  only  in  20,  and  hypertrophy  only  without  renal 
disease  in  2.  In  some  cases  the  association  with  epilepsy  seemed 
accidental ;  in  some  others  the  cardiac  disturbance  may  have  been 
due  to  the  strain  during  the  fits ;  in  others  the  heart-disease  had 
preceded  the  epilepsy,  and  may  have  beon  one  of  its  causes. 

In  20  cases  of  epilepsy  the  patients  had  also  had  chorea.  In  8 
the  epilepsy  existed  first;  in  12  the  chorea  preceded  the  epilepsy, 
in  4  immediately,  in  5  at  an  interval  of  years.  It  seems  probable 
that  the  disturbance  of  the  motor  centres  during  chorea  may  pre- 
dispose to  epilepsy. 

Lecture  II.  Of  the  symptoms  of  the  series  of  cases  which 
formed  the  subjects  of  the  lectures,  the  first  point  examined  was 
time  at  which  attacks  occurred.  Of  840  cases  the  fits  occurred  at 
night  in  one-fifth,  in  the  day  in  rather  more  than  two-fifths,  and 
both  night  and  day  in  rather  less  than  two-fifths.  In  5  per  cent, 
they  occurred  only  in  the  early  mornings.  There  was  no 
difference  in  these  respects  between  the  cases  of  pure  epilepsy, 
and  those  with  hystero-epileptic  symptoms.  An  equal  proportion 
occurred  by  night.  The  first  fit  occurred  in  epileptics  rather  more 
frequently  by  day  than  by  night,  in  hystero-epileptics  much  more 
frequently  by  day.  When  the  first  fit  occurred  in  the  day,  the 
subsequent  fits  occurred  only  in  the  day  in  half  the  cases ;  only  in 
the  night  in  one-seventh,  both  night  and  day  in  one-third.  When 
the  first  fit  occurred  during  the  night,  the  subsequent  fits  occurred 
only  at  night  in  about  two-fifths  of  the  cases,  both  day  and  night 
also  in  about  two-fifths,  by  night  only  in  one-sixth.  If  fits  which 
have  recurred  at  night  only,  commence  to  occur  in  the  day,  they 
commonly  continue  at  night.  If  they  have  existed  only  by  day, 
and  occur  at  night,  they  commonly  cease  by  day.     If  they  have 

VOL.   III.  T 


274  ABSTEACTS  OF  BRITISH 

occurred  both  day  and  night,  they  often  cease  to  occur  in  the  day 
and  continue  at  night,  but  very  rarely  cease  at  night  and  continue 
by  day. 

Of  82  cases  in  menstruating  women,  in  one-twelfth  no  attacks 
occurred  at  the  time  of  menstruation;  in  more  than  half  they 
were  worse  at  those  periods,  commonly  before,  or  during,  men- 
struation, rarely  after. 

Of  the  symptoms  of  the  attacks,  that  selected  for  detailed 
analysis  was  their  modes  of  onset.  "  Auras "  and  "  warnings  "  are 
now  known  to  be  the  effect  on  the  consciousness  of  the  commencing 
change  in  the  brain,  and  so  give  important  information  regarding 
the  region  of  the  brain  on  which  the  process  of  the  fit  begins.  This 
mode  of  investigation  was  initiated  by  Dr.  Hughlings-Jackson. 
The  "  discharge "  may  begin  in  an  intellectual,  motor,  or  sensory 
centre,  and  the  distinction  of  the  two  latter  is  of  great  importance 
in  their  study. 

Of  1 000  cases,  warnings  were  present  in  the  attacks  of  505,  and 
the  results  of  the  analysis  of  the  latter  were  described  at  length. 
The  auras  may  be  referred  to  almost  any  part  of  the  organism, 
but  were  divided,  for  clinical  convenience,  into  seven  groups. 

(1.)  Unilateral  peripheral  aurse  (86  cases)  were  referred  to  one 
side  of  the  tongue  (7),  face  (17),  arm  (45),  leg  (15),  and  trunk 
(2  cases).  No  cases  of  presumably  organic  disease  were  included. 
The  commencement  on  the  tongue  was  less  frequently  by  a  move- 
ment than  by  a  sensation.  The  normal  associations  of  function  were 
reproduced  in  certain  combinations  of  the  aura,  viz.,  with  move- 
ment in  the  lips  and  jaw,  and  with  nausea.  All  cases  commencing 
on  the  tongue  were  right-sided,  which  suggests  (as  does  its  frequent 
paralysis  in  aphasia),  that  its  representation  is  chiefly  on  the  left 
side  of  the  brain.  The  attacks  commenced  in  the  face  as  frequently 
on  one  side  as  on  the  other,  but  much  more  frequently  by  a  motion 
than  by  a  sensation. 

Commencement  in  the  arm,  when  by  movement  (in  eighteen  cases) 
was  almost  always  in  the  hand  as  a  whole  or  arm  as  a  whole; 
when  by  sensation  (in  fourteen  cases)  it  was  commonly  in  a  definite 
part  of  the  hand,  and  never  higher  than  the  wrist.  In  five  other 
cases  the  sensation  was  probably  motor :  a  sense  of  movement 
without  movement.  The  attacks  beginning  by  movement,  or  a 
motor  sensation,  commenced  in  one  arm  as  often  as  in  the  other ; 
those  beginning  by  sensation  began  in  the  left  hand  twice  as  fre- 
quently as  in  the  right.  In  cases  of  progress  before  loss  of  con- 
sciousness, the  course  was  to  the  head,  or  down  the  side  to  the  leg. 


AND  FOREIGN  JOURNALS.  275 

Commencement  in  the  leg  was  by  a  movement  (in  five  cases), 
usually  in  the  foot,  once  in  the  hip ;  or  by  a  sensation  (five 
times),  usually  in  a  definite  part  of  the  foot.  When  the  aura 
progressed  before  loss  of  consciousness,  it  passed  up  the  side  to  the 
head,  or  down  the  arm.  In  these  limb  auras  there  are  two  ways  in 
which  the  second  limb  is  affected,  one  by  passage  by  continuity,  up 
or  down  the  trunk,  and  down  the  second  limb  ;  the  other  by  fresh 
commencement  in  the  extremity  of  the  second  limb,  and  passage  of 
the  aura  up  both.  There  is  reason  to  believe  that  when  the  passage 
is  by  continuity  through  the  trunk,  the  discharge  in  the  sensory 
centre  leads,  and  a  case  was  related  in  which  a  sensory  aura  had 
this  course,  and  motion  was  only  added  when  it  had  gone  down 
the  second  limb,  up  which  the  spasm  passed.  Special  sense  auras 
were  never  associated  with  tongue,  face,  or  leg  auras  ;  and  with  an 
arm  aura  only  when  it  began  with  sensation.  The  known  rela- 
tions of  the  cortical  centres  in  the  brain  afford  only  a  little  help  in 
explaining  the  progress  of  auras ;  probably  because  this  is  largely 
influenced  by  the  position  of  the  undefined  sensory  centres  for  the 
limbs,  in  which  many  discharges  seem  to  begin.  Of  the  fits  com- 
mencing unilaterally,  88  per  cent,  were  purely  epileptic,  12  per 
cent,  presented  hystero-epileptic  symptoms. 

In  the  second  group  were  placed  certain  general  auras,  bilateral 
sensations  in  the  limbs,  tremors,  starts,  malaise,  &c.  The  commence- 
ment was  in  both  arms  in  11  (almost  all  purely  epileptic),  in  the  legs 
in  12  cases  (3  certainly  and  4  probably  hj-stero-epileptic).  Trunk 
auras,  not  visceral,  were  rare,  and  were  referred  to  the  spine  :  the 
attacks  were  all  purely  epileptic.  So  also  were  the  attacks  com- 
mencing by  general  tremor  (13  cases),  and  starts  or  jerkings 
(10  cases).  Malaise  constituted  the  warning  in  15  cases,  and  faint- 
ness  that  of  13  cases ;  and  of  the  attacks  preceded  by  these  general 
sensations  about  one-half  were  hystero-epileptic. 

The  third  group  comprehends  auras  referred  to  certain  viscera, 
mainly  those  to  which  the  pneumo-gastric  nerve  is  distributed ; 
the  epigastric  sensations,  choking,  dyspncea,  nausea,  and  cardiac 
sensations.  These  were  present  in  106  cases.  The  epigastric  aura 
(51  cases)  consisted  of  actual  pain  in  a  third ;  it  was  some- 
times referred  to  the  left  hypochondrium,  but  never  to  the  right. 
When  pain,  it  remained  at  the  epigastrium  until  consciousness  was 
lost.  When  a  vague  sensation,  it  often  passed  up  to  the  head,  or  to 
the  throat  as  choking.  The  latter  sensation  seems  to  be  the  same 
as  the  globus  hystericus,  and  may  be  described  in  identical  terms, 
even  in  organic  disease.      The  warning  was  simply  "  choking," 

T  2 


276  ABSTRACTS  OP  BRITISH 

referred  to  the  throat  in  eighteen  cases,  and  dyspnoea  or  suffocation 
in  six  cases.  These  ascending  auras  seem  referable  to  the  respiratory- 
function  of  the  vagus ;  the  epigastric  pain  seems  connected  with 
the  gastric  functions,  for  in  many  cases  nausea,  and  in  some  retch- 
ing, was  associated.  Cardiac  sensations  constituted  the  warning  in 
16  cases ;  pain  in  2,  a  vague  sensation  in  3,  and  palpitation  in  11. 
Hystero-epileptic  cases  constituted  one-fifth  of  those  with  an  epi- 
gastric aura,  or  with  chest  dyspnoea,  one  half  of  those  with  a 
throat  aura,  and  one-third  of  those  with  a  cardiac  aura. 

The  fourth  group  comprehends  the  aura?  which  consist  in  the 
fact  of  rotation,  or  the  sense  of  giddiness,  described  as  no  less  than 
90  cases.  Most  were  epileptic,  one-sixth  only  being  hystero- 
epileptic.     In  most,  consciousness  was  very  early  lost. 

Sensations  referred  to  the  head  (fifth  group)  preceded  the  fits  in 
50  cases;  vague  in  29;  pain  in  21.  In  one-fourth  of  these  cases 
the  attacks  were  hystero-epileptic,  and  the  proportion  was  nearly 
the  same,  whether  the  warning  was  a  vague  sensation  or  actual 
pain.  Sudden  somnolence  was  the  warning  in  5,  and  sudden 
inability  to  speak,  in  9  cases. 

A  psychical  aura  (sixth  group)  was  described  in  25  cases ;  ah 
emotion  in  10 ;  an  idea  in  15.  The  emotion  was  always  fear,  but 
bore  no  relation  to  fright  as  a  cause.  Associations  with  other  auras 
were  rare ;  and  in  no  case  was  it  combined  with  an  epigastric  sensa- 
tion. Only  cases  were  reckoned  in  which  the  emotion  was  men- 
tioned spontaneously  by  the  patient,  since,  in  most  cases,  with  a 
deliberate  aura,  some  alarm  is  felt.  All  the  cases  were  purely 
epileptic.  The  intellectual  aura  was  commonly  a  vague  idea. 
Several  patients  described  sudden  recollection  of  many  past  events. 
A  sudden  sense  of  strangeness  was  felt  in  a  few  cases. 

The  last  group  consists  of  the  aurae  referred  to  the  special  senses 
(119  cases).  An  olfactory  sensation,  usually  unpleasant,  was 
noted  in  7  cases,  all  purely  epileptic,  a  gustatory  sensation,  de- 
scribed as  a  taste  between  sour  and  bitter,  in  one  case  only.  In  84 
cases,  the  warning  was  referred  to  the  organ  of  vision.  It  was  a 
sensation  in  the  eyeball  in  7  ;  diplopia  in  5.  In  a  few  there  was  an 
apparent  magnification  or  diminution  in  the  size  of  objects,  pro- 
bably connected  with  a  commencing  discharge,  or  inhibition,  of 
the  visual  centre.  Loss  of  sight  preceded  loss  of  consciousness  in 
26  cases  (4  hystero-epileptic).  In  46  cases  the  aura  was  a  visual 
sensation  (35  certainly  purely  epileptic).  In  17,  colours  were  seen, 
which  could  be  described  in  15.  Eed  and  blue  were  the  only 
colours  seen  alone ;  one  of  them  was  always  mentioned,  and  both 


AND  FOREIGN  JOURNALS.  277 

"were  present  in  half  the  cases.  The  order  of  frequency  of  colours 
was  red  (11),  blue  (8),  green  (3),  yellow  (3),  purple  (1).  This  order 
does  not  correspond  with  the  order  in  the  spectrum,  nor  with  the 
size  of  the  fields  of  vision,  but  it  does  with  the  visibility,  of  colours 
in  direct  sunlight  according  to  Cohn,  which  is  red,  blue  and  green 
equal,  yellow,  violet.  In  14  cases  the  aura  was  a  highly  specialized 
sensation,  a  visual  idea,  which  in  one  case  succeeded,  in  another 
coincided  with,  a  simpler  visual  sensation ;  in  the  others,  came  alone 
and  first,  and  must  have  been  due,  not  to  "  loss  of  control "  but  to 
the  discharge.  Associated  auras  were  rare,  but  one  instructive 
case  was  related  at  length ;  an  epigastric  sensation  ascended  through 
the  chest  as  beating,  and  then  was  heard  as  knocking.  This  was 
followed  by  hissing,  then  by  the  vision  of  an  old  woman  holding 
out  a  strongly  smelling  substance,  then  by  two  lights ;  lastly  a 
sense  of  choking  immediately  preceded  loss  of  consciousness.  The 
only  anatomical  fact  recorded  regarding  these  auras  was  a  case, 
published  by  the  lecturer,  in  which  attacks  preceded  by  a  flash  of 
light  and  micropsy  were  due  to  a  tumour  behind  the  angular 
gyrus. 

Auditory  warnings  existed  in  27  cases ;  sudden  loss  of  hearing 
in  6  ;  an  auditory  sensation  in  21 ;  a  loud  sensation  of  low  specialisa- 
tion, "crash,"  "blow,"  "hissing,"  &c,  in  12;  in  others  an  "audi- 
tory idea."  In  several  cases  auditory  and  visual  sensations  were 
associated,  and  in  some  they  were  alike  in  character,  i.e.  in  degree 
of  specialisation.  An  unpublished  case  was  mentioned,  which  the 
lecturer  had  watched  with  Dr.  Hughlings-Jackson,  in  which 
attacks  preceded  by  an  auditory  sensation  referred  to  one  ear  were 
due  to  a  tumour  which  had  commenced  in  the  white  substance 
of  the  opposite  temporo-sphenoidal  lobe,  within  the  convolution  in 
which  Ferrier  places  the  auditory  centre. 

Of  the  other  symptoms  of  attacks,  time  permitted  mention  of 
only  one  or  two.  Pallor  of  face  is,  it  was  urged,  much  less  fre- 
quent than  current  statements  suggest,  and  in  both  major  and 
minor  attacks  may  be  entirely  absent.  The  tonic  and  clouic 
spasm  are  continuous ;  the  interruptions  may  be  felt  by  the  hand 
before  they  are  visible  to  the  eye.  Slight  attacks  may  consist  of 
either  clonic  or  tonic  spasm  :  when  the  latter  only,  the  attack  is 
allied  to  hystero-epilepsy.  The  hands  in  an  epileptic  fit  are  not 
often  clenched ;  more  often  they  are  in  an  interosseal  position,  the 
wrists  flexed,  the  fingers  flexed  at  the  metacarpo-phalangeal,  ex- 
tended at  the  other  points ;  the  thumb  bent  in  :  an  exaggeration  of 
the  position  seen  in  tetany. 


278  ABSTRACTS  OF  BRITISH 

Some  forms  of  hystero-epileptic  attacks  seen  in  this  country 
were  then  described:  Their  characteristic  is  co-ordinated  spasm, 
movements  of  quasi-purposive  character.  They  have  alliances 
with  epilepsy  and  insanity  as  well  as  with  hysteria  in  its  simpler 
forms.  In  the  first  variety,  resembling  most  that  described  by 
Charcot,  the  patient  suddenly  falls,  and  passes  into  a  condition  in 
which  tonic  spasm,  often  with  outspread  arms,  alternates  with  violent 
movements,  opisthotonos,  wild  movements  of  the  limbs,  &c.  There 
is  often  internal  strabismus,  and  frequently  manifestations  of  intense 
terror.  When  severe,  this  frenzy  and  violence  might  be  described  as 
compressed  mania.  Sometimes  there  is  a  curious  theiro-mimicry,  and 
the  patients  will  bark,  and  will  bite  in  a  strangely  animal  manner. 
In  women  ovarian  tenderness  sometimes  exists,  but  the  lecturer 
had  never  known  ovarian  pressure  in  the  natives  of  this  country 
succeed  in  bringing  on  these  attacks,  and,  although  it  will  some- 
times arrest  them,  cutaneous  faradisation  does  so  more  readily.  Such 
attacks  occur  most  commonly  in  girls  and  women,  but  also  in  boys 
and  occasionally  in  adult  men.  A  second  variety  is  characterised 
by  violent  emprosthotonos,  a  third  by  curious  rhythmical  movements 
of  flexion  and  extension  of  the  legs,  and  a  fourth  by  intense  dyspnoea, 
reaching  almost  the  point  of  suffocation.  An  instance  of  the  latter, 
a  somewhat  rare  form,  was  narrated  at  length. 

Lecture  III.  The  third  lecture  was  devoted  to  pathology  and 
treatment.  In  idiopathic  epilepsy  the  facts  of  pathological  ana- 
tomy are  of  most  doubtful  value.  The  problem  of  pathology 
resolves  itself,  in  the  main,  into  four  questions :  What  is  the  seat 
of  the  "  discharge  "  which  causes  the  symptoms  of  the  fit  ?  Is  the 
seat  of  the  discharge  the  seat  of  the  disease?  How  far  does  such 
"  discharge  "  explain  all  the  symptoms  of  the  fit  ?  What  is  the  ulti- 
mate nature  of  the  morbid  state  which  causes  the  discharge?  The 
word  discharge  was  used,  without  theory,  to  signify  the  sudden 
liberation  of  nerve-force. 

With  regard  to  the  first  question,  the  seat  of  the  disoharge,  there 
are  two  classes  of  facts.  (1)  There  is  a  "  convulsive  centre "  in 
the  medulla,  capable  of  giving  rise  by  its  action  to  general  convul- 
sions (Nothnagel).  (2)  Of  all  regional  diseases,  lesions  of  the 
cortex  stand  incomparably  first  as  a  cause  of  Convulsion,  and  ex- 
periment demonstrates  that  convulsions  may  be  produced  by  irrita- 
tion of  the  motor  region  of  the  convolutions.  But  even  the  second 
set  of  facts  alone  scarcely  warrant  the  conclusion  that  epilepsy  is 
a  cortical  disease,  because  deeper  motor  structures,  excitable  from 


AND   FOREIGN  JOURNALS.  279 

the  surface  (Burdon-Sanderson),  may  be  the  parts  which  discharge 
primarily  in  convulsions,  quite  similar  to  those  produced  by  ex- 
perimental irritation.  The  affection  of  consciousness  does  not 
prove  that  the  discharge  begins  in  the  highest  centres,  since  dis- 
charges in  lower  centres  may  affect  the  centres  above  them  as  well 
as  those  below  (Robertson),  and  in  current  theory  an  explanation 
of  loss  of  consciousness  is  found  in  vaso-motor  spasm.  Thus  neither 
pathology  nor  experiment  enables  us  to  exclude  the  lower  centres, 
and  the  latest  writer  of  a  systematic  account  of  the  disease,  Noth- 
nagel,  finds  no  reason  to  doubt  that  epilepsy  is  primarily  a  disease 
of  the  convulsive  centre  in  the  medulla  oblongata. 

The  clinical  study  of  modes  of  onset,  however,  gives  us  further 
help.  In  the  cases  (no  inconsiderable  number)  in  which  the 
warning  is  a  special  sense  aura,  or  psychical  aura,  we  must 
conclude  that  the  process  of  the  fit  begins  in  the  special  sense 
and  intellectual  centres,  within  the  hemispheres.  Thus  the 
teaching  of  pathology  is  right  in  its  indications,  and  we  must 
conclude  that  in  many  fits  the  discharge  commences  in  the  cere- 
bral hemispheres.  If  so,  what  facts  are  there  to  indicate  that  in 
epilepsy  the  fits  ever  do  commence  in  the  medulla  ?  Such  facts 
are,  it  must  be  confessed,  scanty.  The  pneumogastric  aura?,  i.  e., 
the  visceral  auras  referable  to  the  respiratory  and  gastric  centres, 
might  be  regarded  as  evidence  that  the  convulsions  depend  on  dis- 
charges in  the  medulla.  But  these  centres  are  certainly  (as  Dr. 
Hughlings-Jackson  has  insisted)  represented  in  the  hemispheres  ; 
they  are  readily  affected  in  emotional  disturbance ;  and  facts  men- 
tioned in  the  last  lecture  show  that  they  may  be  easily  disturbed 
in  discharges  unquestionably  originating  in  the  hemispheres.  But 
we  must  not  conclude,  from  the  absence  of  direct  evidence,  that  no 
fits  commence  in  the  medulla,  and  in  a  curious  case  under  the  care 
of  Dr.  Bamskill,  the  symptoms  suggested  this  seat,  for  there  was 
general  powerlessness,  and  the  attacks  could  be  at  any  time  brought 
on  by  passive  movements  of  the  trunk.  The  wide  extent  and 
varied  character  of  the  initial  symptoms  of  fits  points  (as  Dr. 
Hughlings-Jackson  has  urged)  to  their  probable  origin  in  any 
grey  matter  in  which  sensori-motor  processes  occur,  but  the  evi- 
dence that  they  originate  in  the  hemispheres  is  much  more 
frequent  and  much  stronger  than  that  they  commence  lower  down. 

The  question  whether  the  seat  of  the  discharge  is  the  seat  of  the 
disease  may  be  considered  together  with  the  third  question,  does 
the  discharge  which  causes  the  convulsion  explain  all  the  symp- 
toms of  the  attack?     According  to   current  theories  vaso-motor 


280  ABSTRACTS  OF  BRITISH 

spasm  is  the  cause  of  loss  of  consciousness,  and  some  have  added, 
of  the  motor  discharge  itself.  But  vaso-motor  spasm  is  not  neces- 
sary to  explain  the  loss  of  consciousness,  since  the  "  discharge,"  as 
we  have  seen,  may  produce  it.  On  what  direct  evidence  has  the 
vaso-motor  theory  "been  based  ?  Mainly  on  the  facts  that  there  is 
pallor  of  the  face  in  an  epileptic  fit,  and  that  cerebral  anasmia  will 
cause  convulsions.  But,  it  was  urged  in  the  previous  lecture,  that 
pallor  of  face  is  often  absent.  Moreover  we  cannot  infer  from  the 
state  of  surface- vessels  the  state  of  deeper  vessels.  Pallor  of  face, 
when  it  occurs,  may  be  the  effect  of  the  cerebral  discharge,  not  an 
indication  of  its  cause.  Between  the  fact  that  anasrnia  of  brain 
will  cause  convulsions,  and  that  vaso-motor  spasm  is  the  cause  of 
any  of  the  phenomena  of  epilepsy  is  an  unbridged  gulf,  which  is 
widened  by  every  increase  in  our  knowledge  of  the  clinical  history 
of  the  disease.  Dr.  Hughlings-Jackson's  theory,  that  local  vaso- 
motor spasm  results  from  the  commencing  discharge  and  deter- 
mines its  spread,  seems  unneeded  and  opposed  to  the  fact  that 
functional  activity  of  organs  (and  of  the  brain,  Ferrier)  causes 
dilatation  of  their  vessels.  Thus  it  is  urged  that  all  the  phe- 
nomena of  epilepsy  may  be  explained  by  the  instability  of  grey 
matter,  and  that  there  is  no  warrant  or  need  to  go  farther  in  ex- 
plaining. Epilepsy  is  thus  regarded  as  without  any  uniform  seat : 
as  a  disease  of  tissue. 

What  is  the  probable  nature  of  the  tissue-change?  The  "over- 
action  "  has  been  regarded  as  the  indication  of  an  increased  func- 
tional and  therefore  nutritive  activity  (Hughlings-Jackson),  or  as 
really  due  to  a  general  impairment  of  functional  power  and 
under-nutrition  (especially  by  Dr*  Eadcliffe).  Modern  physiology 
seems  to  indicate  the  direction  in  which  an  answer  is  to  be  sought. 
The  notion  that  there  must  be  a  resistance  to  action  in  nerve-cells, 
opposing  the  tendency  to  liberate  energy,  has  underlain  such  ex- 
pressions as  "  nerve  tension,"  but  has  only  lately  been  formulated, 
and  promises  to  give  clearer  views  of  many  physiological  problems, 
and,  as  Dr.  Einger  has  shown,  of  many  pathological  problems  also. 
The  amount  of  latent  energy  in  the  brain,  held  in  check,  may  be 
infinitely  greater  than  any  manifestations  of  it  would  suggest. 
The  phenomena  of  epilepsy  better  accord  with  the  notion  of  an 
instability  of  resistance  than  an  excess  of  the  energy-producing 
function.  Thus  the  convulsions  from  loss  of  blood  may  be  best 
explained,  and  so  also  may  the  arrest  of  a  commencing  fit  by  a 
peripheral  impression.  Once  arrested  (by  raising  resistance),  it 
does  not  recur,  as  it  would  if  dependent  on  primary  overaction. 


AND   FOREIGN  JOURNALS.  281 

The  internal  resistance  is  probably  a  higher  function  than  the  trans- 
formation of  force,  and  so  an  apparent  over-action,  an  excessive 
liberation  of  energy,  may  be  the  result  of  imperfect  nutrition. 

The  phenomena  of  hystero-epilepsy  are,  it  was  suggested,  due 
to  an  instability  and  discharge  of  grey  matter  of  different  position 
and  perhaps  character.  When  succeeding  an  attack  of  epilepsy, 
major  or  minor,  they  have  been  regarded  by  Dr.  Hughlings-Jackson 
as  due  merely  to  loss  of  control  by  the  discharge  of  higher  centres, 
on  the  ground  that  actual  discharge  can  only  itself  cause  inco- 
ordinate "  brutal "  effects.  But  the  co-ordinated  spasm  of  a  hystero- 
epileptic  fit  may  commence  in  the  first  movement  of  the  fit ;  and 
the  discharge  of  epilepsy  sometimes,  as  in  cases  mentioned  in  the 
last  lecture,  may  cause  special-sense  or  intellectual  symptoms  of 
very  high  specialisation.  In  cases  in  which  co-ordinated  con- 
vulsion succeeds  an  epileptic  fit,  the  hypothesis  of  loss  of  control 
seems  scarcely  adequate.  It  may  be  one  element,  but  an  insta- 
bility of  the  lower  centre  seems  essential ;  for  why  should  attacks 
apparently  quite  similar  be  never  followed  by  these  symptoms? 
Automatic  action  commonly  succeeds  epilepsy,  but,  it  was  urged, 
may,  in  rare  cases,  occur  without  preceding  epileptic  symptoms. 
It  was  suggested,  therefore,  that  all  co-ordinated  and  automatic 
phenomena,  often  succeeding  epileptic  symptoms,  may  sometimes 
occur  alone.  In  some  cases  they  may  be  due  only  to  loss  of 
control,  but  they  have  commonly  an  anatomical  basis  in  lessened 
stability  of  the  centres  on  which  they  depend;  that  all  may  be 
due  to  a  primary  discharge  of  the  unstable  centre,  but  that  the  fre- 
quency with  which  they  occur  alone  lessens  as  we  ascend  the  scale 
of  complexity.  Automatic  action  is  much  rarer  without  preceding 
epileptic  symptoms  than  are  the  "  co-ordinated  convulsions." 

The  clonic -spasm  of  the  later  stage  of  an  epileptic  fit  is  con- 
tinuous with  the  earlier  tonic  spasm,  and  may  bo  due  to  the  venous 
congestion,  not  exciting  it,  but  interrupting  and  arresting  the 
previous  tonic  spasm.  Local  slight  epileptiform  seizures  com- 
monly consist  of  clonic  spasm  only,  and,  as  the  discharge  spreads 
and  becomes  intense,  the  spasm  becomes  tonic.  The  two  are  thus 
rather  variations  of  the  same  form,  than  of  different  kind. 

The  treatment  of  epilepsy,  it  was  remarked,  is  a  subject  on 
which  numerical  analysis  gives  little  help,  because  so  many 
patients,  whose  fits  come  under  treatment,  relapse  when  treatment 
is  relinquished.  The  time  available  permitted  little  more  than  a 
statement  of  the  remedies  most  useful  in  562  cases,  in  which  the 
effect  of  treatment  was  carefully  noted.     The  results  showed  that, 


282  ABSTRACTS  OF  BRITISH 

while  we  must  not  rely  exclusively  on  bromides,  on  these  our  chief 
trust  must  still  be  placed.  The  value  and  method  of  use  of 
bromides,  alone  and  in  combination,  of  belladonna,  digitalis,  opium, 
Indian  hemp,  picrotoxin,  &c,  and  the  occasional  value  of  borax, 
were  then  alluded  to.  After  referring  to  the  treatment  of  hystero- 
epilepsy,  especially  by  apomorphia,  the  lecturer  remarked,  in  con- 
clusion, that  although  the  condition  of  many  epileptics  was  still 
gloomy  enough,  yet  the  present  generation  had  witnessed  an 
advance  in  the  treatment  of  the  disease  equalled  in,  perhaps,  no 
other  branch  of  therapeutics.  Thanks  to  the  influence  of  one 
drug,  the  use  of  which  in  epilepsy  was  due  wholly  to  Fellows 
of  that  College,  hundreds  of  sufferers  had  been  cured,  and  thou- 
sands were  leading  useful  lives  who  would  otherwise  have  been 
incapacitated  by  the  disease.  For  all  the  victims  of  the  disease,  we 
might  surely  trust  that  the  progress  of  the  recent  past  is  the 
dawn  of  a  brighter  day. 

W.  E.  G. 

On  the  Disease  called  Sturdy  in  Sheep,  in  its  Relation  to 

Cerebral  Localisation. — In  the  January  number  of  the  Journal 
of  Anatomy  and  Physiology  I  published  an  article  with  the  above 
title,  and  in  the  present  communication  I  propose  to  give  a  brief 
summary  of  those  points  on  which  I  dwelt  at  some  length  in  that 
paper.  But  to  render  my  remarks  clearer,  it  will  be  necessary 
that  I  first  sketch  in  outline  the  disease  called  Sturdy,  which  is 
so  named  from  its  prominent  symptom  being  a  rotatory  movement  of 
a  very  peculiar  character.  It  is  common  among  sheep  wherever 
they  are  herded  together  and  tended  by  dogs,  the  latter  point 
being  of  special  importance,  for  the  disease  consists  in  the  presence 
in  the  brain  of  the  sheep  of  an  hydatid,  the  caenurus  cerebralis, 
which  is  a  cystic  or  bladder-worm,  and  is  the  larval  stage  of  tbe 
taenia  caenurus,  one  of  the  six  varieties  of  tape-worm  infesting  the  dog. 
This  fact  having  been  conclusively  shown  by  Kuchenmeister, 
it  is  not  difficult  to  trace  the  course  of  events  in  the  case  of  a 
sheep-dog  afflicted  with  tape-worm.  He  wanders  about,  distri- 
buting the  ova  of  the  taenia  on  the  pastures,  where  they  are 
swallowed  by  the  sheep  while  grazing.  "When  they  have  reached 
the  animal's  stomach,  they  are  acted  on  by  the  gastric  juice,  their 
hard  coverings  are  dissolved,  and  the  small  six-hooked  embryos 
escape.  By  means  of  their  hooks  they  bore  their  way  into  the 
blood-vessels  and  are  carried  to  the  brain,  where  they  take  up 
their  abode,  either  from  their  having  some  predilection  for  that 


AND  FOREIGN  JOURNALS.  283 

organ,  or  because  the  peculiar  cerebral  circulation  of  the  sheep, 
with  its  wonderful  rete  mirabile,  favours  their  doing  so.  Having 
reached  the  brain,  they  make  their  way  out  of  the  blood-vessels, 
part  with  their  hooks,  and  gradually  acquire  the  bladder-worm 
state,  varying  in  size  from  a  pin's  head  to  a  walnut.  After  a  time 
they  assume  the  polycephalous  condition,  and  an  hydatid  in  this 
stage  of  development  consists  of  a  thin  transparent  bag  or  mem- 
brane, containing  a  clear  fluid,  and  having  a  number  of  small 
whitish  spots  like  eggs  on  its  surface,  disposed  in  regular  lines. 
These  are  the  heads  of  the  hydatid,  and  I  wish  to  direct  special 
attention  to  the  fact  that  they  are  exsertile  or  protrusible,  a  charac- 
teristic of  some  importance.  An  hydatid  cyst  of  this  nature  may 
attain  any  size,  but  is  not  actually  incorporated  with  the  brain 
substance,  being  surrounded  with  areolar  tissue.  One  other  point 
connected  with  the  history  of  this  hydatid  demands  notice.  It  is 
this :  that  after  a  variable  time  it  causes  softening  of  the  skull  in 
its  vicinity,  the  bony  roof  of  the  cranium  disappearing  both  by 
reason  of  the  pressure,  and  also  probably  from  the  protrusible 
heads  of  the  hydatids  not  only  removing  the  brain  substance  but 
also  eating  away  the  bone  itself.  This  soft  and  yielding  spot 
forms  a  guide  to  the  situation  of  the  hydatid. 

Passing  next  to  the  symptoms  which  this  malady  gives  rise 
to,  we  find  that  they  of  course  vary  with  the  stage  which  it  has 
reached.  Its  earliest  indications  are  those  of  cerebral  congestion, 
as  shown  by  redness  of  the  eyes  and  dilatation  of  the  pupils, 
together  with  a  desire  on  the  part  of  the  animal  affected  to  separate 
itself  from  the  rest  of  the  flock.  It  is  also  dull  and  listless  in  its 
movements,  and  in  its  desire  for  food.  Any  temporary  improve- 
ment in  these  symptoms  is  soon  followed  by  signs  of  increased 
nervous  irritation,  the  creature  being  easily  and  groundlessly 
alarmed,  and  delighting  to  stand  over  running  water,  as  if  the 
murmuring  sound  caused  by  it  had  some  soothing  influence  over 
it.  In  addition,  there  is  difficulty  in  grazing,  the  head  often 
turning  to  one  side,  to  be  soon  followed  by  the  rotatory  movement 
which  is  characteristic  of  the  disease.  When  once  this  is  developed 
it  goes  on  increasing  in  frequency  to  such  an  extent  that  the 
animal  is  unable  to  feed  ;  and  though  eventually  the  movement 
may  diminish  in  intensity,  or  even  cease  altogether,  the  creature 
becomes  so  exhausted  and  emaciated  that  at  last  it  dies,  unless 
operative  interference  should  be  undertaken  for  the  removal  of  the 
cyst;  but  even  this,  as  usually  performed,  is  a  somewhat  fatal 
operation,  owing  to  the  admission  of  septic  air,  which  sets  up 


284  ABSTRACTS  OP  BRITISH 

putrefaction  in  the  contents  of  the  cyst,  leading  to  inflammation  and 
death.  Such  was  the  course  of  events  in  the  first  case  of  sturdy 
that  came  under  my  notice ;  and  I  fancy,  from  what  I  can  learn,  it 
is  the  chief  cause  of  mortality  in  the  cases  submitted  to  operation. 

Space  does  not  allow  me  to  go  into  the  discussion  of  any  of  the 
individual  cases  of  sturdy  in  their  bearing  on  the  theory  of  locali- 
sation of  brain  function,  although  some  of  them  presented  points  of 
considerable  interest.  I  must  content  myself  with  remarking 
only  on  one  or  two  other  points  which  the  disease  brings  out,  and 
chief  among  these  is  the  cause  of  the  rotatory  movements  which 
are  so  characteristic  of  the  malady,  and  which  also  occur,  as  is  well 
known,  in  animals  that  have  been  experimented  on.  In  this  latter 
case  they  are  seen  after  very  different  operations,  and  Brown- 
Sequard  has  tabulated  a  number  of  the  injuries  that  cause  them, 
showing  they  are  confined  to  no  particular  structure.  This  fact  is 
also  borne  out  by  the  disease  of  sturdy,  for  they  declare  themselves 
in  that  affection  irrespective  of  the  structure  involved.  Some 
explain  them  by  the  theory  that  they  are  due  to  spasms  and 
paralysis  of  the  muscles  on  the  side  towards  which  the  movement 
takes  place,  and  more  recently  in  a  clinical  lecture,  published  in 
the  Lancet,  December  13,  187*9,  I  find  that  Dr.  Broadbent 
attributes  their  occurrence  in  animals  to  the  association  of  the 
nerve-nuclei  of  the  fore  and  hind  limbs  in  connection  with  their 
mode  of  progression.  But  from  my  own  observations  in  the  cases 
of  sturdy  which  I  have  seen,  I  am  inclined  to  regard  these  move- 
ments as  having  another  origin.  I  look  upon  them  as  caused  by 
the  presence  of  the  hydatid  itself  in  the  brain,  which  so  acts  as  a 
cerebral  irritant  that  it  sets  up  manifestations  of  nervous  energy, 
interferes  with  the  proper  working  of  the  general  co-ordinating 
mechanism  of  the  brain,  and  disturbs  the  delicate  and  sensitive 
apparatus  of  the  nervous  system.  As  a  result  of  this,  inhibitory 
influences  are  brought  into  play,  which  act  on  the  will  and  also  on 
the  different  senses,  which  are  not  only  affected,  but  it  may  be 
thrown  into  abeyance.  Now  we  know  how  completely  this  body 
of  ours  depends  for  its  daily  activity  and  movements  on  the 
integrity  and  healthy  working  of  the  channels  through  which 
travel  the  various  impulses  that  invade  our  frame.  No  better 
illustration  of  this  can  be  given  than  the  extent  to  which  ordinary 
locomotion  depends  on  the  integrity  of  sight.  As  Mayo  long  since 
put  it,  "  we  lean  on  our  eyesight  as  on  crutches."  These  remarks 
apply  with  equal  if  not  greater  force  to  animals,  for  we  are  aware 
that  Longet  and   Flourens   produced   vertiginous   movements  in 


AND  FOREIGN  JOURNALS.  285 

pigeons  by  blinding  or  evacuating  the  humours  of  the  eye.  Struck 
by  the  fact  that,  as  far  as  I  had  seen,  the  rotatory  movement  was 
always  to  the  side  on  which  the  cyst  was,  I  was  led  to  look  care- 
fully into  the  state  of  vision,  and  I  invariably  found  that  when 
there  was  present  this  rotatory  movement,  there  was  impairment  of 
sight  on  the  opposite  side  of  the  body. 

The  conclusion  then  that  I  was  led  to  draw  was  that  while  the 
presence  of  the  hydatid  in  the  brain  sets  in  action  nervous  force, 
which  the  weakened  will  of  the  animal  is  unable  to  control,  the 
direction  of  the  movements  is  determined  by  the  side  on  which  vision 
is  impaired.  There  seems  to  me  further  confirmation  of  this  in  the 
fact  that  when  the  disease  becomes  far  advanced,  and  the  sight  in 
both  eyes  is  affected,  as  is  sometimes  the  case,  the  vertiginous 
movements  cease.  Upon  these  grounds  this  disease  seems  to  me 
valuable,  inasmuch  as  it  affords  us  an  explanation  of  the  cause  of 
the  so-called  "  circus  "  movements  seen  after  experimental  opera- 
tions, and  also  furnishes  us  with  a  clue  as  to  the  influences  which 
determine  the  direction  of  these  movements. 

Lastly,  I  would  direct  attention  to  the  following  fact,  to  which  I 
have  already  incidentally  alluded,  that  the  feasibility  of  removing 
the  cyst  must  not  be  lost  sight  of.  Apart  from  the  procedure 
affording  a  good  means  of  testing  the  value  of  antiseptic  and  non- 
antiseptic  methods  of  treating  wounds  of  the  cranium,  to  the 
physiologist  it  would  be  still  more  valuable,  for  it  would  allow  of 
his  operating  at  definite  stages  of  the  disease,  or  whenever  particular 
symptoms  supervened.  Ho  might  thus  ascertain  exactly  the  lesion 
present,  and  whether  the  symptoms  observed  were  temporary  or 
permanent.  The  only  precautions  necessary  would  be  to  wait 
until  the  softening  of  the  skull  gave  some  indications  of  the 
situation  of  the  cyst,  and  to  perform  the  operation  with  antiseptic 
precautions  (Lister's  method),  so  as  to  reduce  to  a  minimum  the 
chance  of  any  subsequent  putridity  and  inflammation,  which  might 
interfere  with  the  observations  made.  In  support  of  this  sugges- 
tion I  would  only  briefly  allude  to  one  case  in  which  I  removed  the 
cyst  by  operative  interference.  In  that  case  one  of  the  chief 
symptoms  was  loss  of  vision  in  both  eyes,  but  the  animal  was  dull 
and  lethargic  to  a  degree,  and  reminded  one  of  a  creature  deprived 
of  its  cerebral  hemispheres.  In  a  few  days  after  operation  it 
recovered  its  sight,  and  was  restored  to  its  usual  health  and  habits 
of  life,  so  that  one  could  not  have  told  that  there  had  been  anything 
wrong  with  it.  When  it  was  killed,  some  weeks  after,  I  found  that 
the  cyst  had  occupied  a  place  in  the  brain  closely  approximating 


286  ABSTRACTS   OF   BRITISH 

to  Ferrier's  centre  for  sight.  Now  had  I  not  operated  on  it  I  should 
have  regarded  it  as  a  case  in  which  the  visual  centre  had  "been 
destroyed,  but  the  complete  return  of  that  sense  after  operation 
indicated  that  it  was  really  only  in  abeyance.  In  other  words,  the 
organ  of  sight  was  temporarily  involved,  owing  to  the  disturbance 
set  up  in  the  mechanism  of  the  brain  by  the  presence  of  such  an 
irritant  as  we  have  seen  that  this  lrydatid  is.  This  return  of  a 
function  that  seemed  destroyed  as  soon  as  the  source  of  irritation 
was  removed,  is  only  another  instance  of  how  careful  we  should  be 
in  drawing  conclusions  from  experimental  inquiries,  a  caution  fully 
borne  out  by  Goltz's  numerous  physiological  experiments. 

George  T.  Beatson,  B.A  (Cantab.),  M.D.  (Edin.). 
Tripier  on  Anaesthesia  from  Cortical  Lesions.     (Bevue 

mensuelle,  January  and  February  1880.) — In  this  memoir  M.  Tri- 
pier reviews  the  various  explanations  which  have  been  given  of  the 
paretic  or  paralytic  symptoms  resulting  from  cortical  lesions,  and 
gives  the  details  of  some  recent  experiments  he  has  made  (in  four 
dogs  and  one  monkey),  as  well  as  several  clinical  cases  in  support 
of  the  thesis,  that  lesions  strictly  cortical  cause  not  only  motor 
symptoms  but  also  defect  of  sensibility,  principally,  but  not  exclu- 
sively, tactile. 

In  his  previous  experiments,  in  which  he  had  shown  that  dogs 
never  really  recover  entirely  from  cortical  lesions,  and  that  tho 
defect  in  mobility  could  always  be  reproduced  by  morphia,  he  had 
failed  to  detect  any  deficiency  in  sensation ;  but  in  the  experiments 
here  recorded,  made  with  the  special  object  of  testing  the  sensi- 
bility, he  finds  that  after  lesion  of  the  sigmoid  gyrus,  there  is  not 
merely  paresis  of  the  limbs,  but  also  deficient  reaction  to  cutaneous 
stimuli — pricking  with  a  pin — on  the  affected  side.  This  is  most 
marked  in  the  face  and  paw,  but  is  more  or  less  general,  and  may 
be  observed  immediately  after  the  lesion,  or  even  up  to  nine 
months  afterwards. 

He  concludes  from  this  that  the  sensibility  is  blunted  or  deficient. 

He,  however,  opposes  the  views  of  Schiff,  &c,  that  the  defect  in 
mobility  is  dependent  on  the  deficient  sensibility,  and  gives  expe- 
rimental evidence  of  the  fact  that  division  of  the  sensory  nerves  of 
the  limb  does  not  cause  such  motor  disorders  as  result  from  cortical 
lesions.  The  motor  symptoms  are  therefore  the  direct  effect  of  the 
cortical  lesions,  but  these  are  also  combined  with  defect  in  sensi- 
bility, though  the  two  are  independent  of  each  other. 


AND  FOREIGN  JOURNALS.  287 

The  clinical  cases  adduced  are  cases  of  hemiplegia  combined 
with  hemianaesthesia,  of  greater  or  less  degree,  in  which  no  other 
lesion  was  discernible  post-mortem  than  cortical  lesion,  the  ganglia 
and  internal  capsule  being  to  all  appearance  intact.  He  is  of 
opinion  that  there  is  no  special  sensory  region  in  the  cortex,  but 
that  the  lesions  which  mainly  cause  hemiplegia  (fronto-parietal), 
also  cause  hemianaesthesia.     The  latter,  however,  is  more  transient. 

[M.  Tripier's  argumentation  is  not  very  conclusive.  His  clinical 
facts  prove  nothing.  He  might  have  cited  cases  with  similar 
symptoms  without  discernible  lesion  in  the  cortex  or  elsewhere. 
It  has  been  indisputably  proved,  in  opposition  to  M.  Tripier's  views, 
that  we  may  have  most  complete  motor  paralysis  from  cortical 
lesions,  with  full  retention  of  sensibility  both  to  tactile  and  painful 
stimuli. 

Assuming  the  complete  accuracy  of  M.  Tripier's  experimental 
data,  they  prove  nothing  beyond  deficient  reaction  to  stimuli. 
That  this  deficiency  is  on  the  sensory  side  is  an  inference  which  is 
not  admissible  until  a  clear  discrimination  can  be  made  between 
psycho-motor  and  mere  reflex  reaction.  Such  a  standard  M. 
•Tripier  has  not  supplied,  and  to  do  so  is  no  easy  matter.  An 
animal  may  not  react  to  a  cutaneous  stimulus,  not  because  it  does 
not  feel  it,  but  because  its  volitional  power  is  impaired.  Even  as 
M.  Tripier's  own  data  show,  the  reaction  to  a  painful  stimulus, 
such  as  would  normally  excite  reflex  movements,  is  as  distinct  on 
the  one  side  as  the  other.] 

Sommer  on  Diseases  of  the  Cornu  Ammonis  (ArcMv  fur 

Psychiatrie.  Bd.  x.  Heft  3). — Sommer  tabulates  90  cases,  collected 
from  various  sources,  in  which  the  hippocampus  was  affected  along 
with  other  cerebral  regions,  from  which  it  is  clear  that  epilepsy 
is  frequently  associated  with  degeneration  in  this  region  and  its 
neighbourhood.     He  estimates  the  proportion  at  30  per  cent. 

The  lesions  are  divided  into  two  principal  forms:  1,  the  classic 
form,  described  first  by  Meynert,  in  which  there  is  atrophy  and 
sclerosis  in  one  or  both  cornua ;  and  2,  lesions  of  various  kinds,  such 
as  softening,  softening  with  redness,  redness  and  punctiform 
haemorrhages,  pressure,  &c.  The  proportions  in  which  the  various 
affections  occur  are  stated  in  a  tabular  form.  A  detailed  descrip- 
tion is  given  of  the  microscopical  characters  of  the  degeneration 
which  occurs. 

Affections  of  the  hippocampus  in  epileptics  are  associated  in  a 


288      ABSTRACTS  OF  BRITISH  AND  FOREIGN  JOURNALS. 

large  number  of  cases  with  excentric  sensory  disturbances,  indica- 
ting that  the  sensory  centre  is  here,  or  in  close  relation  with  it. 

Of  the  90  cases  analysed,  38  bad  sensory  disturbances  in  the 
form  of  hyperesthesia,  paresthesia,  and  anaesthesia. 

Of  the  52  negative  cases,  the  records  are  either  incomplete,  or  the 
conditions  were  such  as  to  preclude  any  observations  on  this  point. 

Of  the  38  positive  cases,  27  relate  to  affections  of  common  sensa- 
tion ;  anaesthesia  7  times,  hyperesthesia  3  times,  paresthesia  (for- 
mication, &c),  and  actual  hallucinations  15  times,  and  lastly  2  in 
which,  owing  to  the  mental  condition,  it  could  only  be  inferred. 
Frequently  the  common  sensory  disturbances  were  associated  with 
illusions  of  hearing  and  sight,  less  frequently  of  smell  and  taste. 
Occasionally,  however,  these  latter  were  alone  affected  without 
implication  of  common  sensation. 

Our  author  regards  it  as  beyond  doubt  that  there  is  a  direct  rela- 
tion between  degeneration  of  the  hippocampus  and  the  disturbance 
of  common  sensibility. 

He  next  proceeds  to  the  consideration  of  the  experimental,  ana- 
tomical, and  other  clinical  evidence  in  favour  of  the  view  that  the 
hippocampus  is  the  centre  of  common  sensation. 

The  first  is  furnished  by  Ferrier's  experiments,  which  are  briefly 
analysed. 

The  anatomical  evidence. is  as  yet  incomplete.  He  refers  to  the 
researches  of  Meynert  and  others,  in  which  it  appears  that  there  is 
a  direct  relation  between  this  region  and  the  sensory  tracts  of  the 
spinal  cord. 

The  clinical  evidence  is  also  as  yet  very  deficient.  There  are 
only  two  cases  on  record,  one  of  these  even  doubtful,  which  indicate 
the  sensory  function  of  the  hippocampus. 

The  first  of  these,  related  by  Chvostek  (Wien.  med.  Wochensch. 
1871,  No.  37-39),  was  a  case  of  typhus  with  delirium,  headache, 
and  other  cerebral  symptoms.  This  was  in  1853.  Diminution  of 
the  sensibility  of  the  left  arm  and  leg,  with  formication  and  slight 
paresis  remained,  and  at  a  later  period  paralysis  agitans  showed 
itself  on  the  left  side.  Death  occurred  from  phthisis  in  1871. 
Section  showed  atrophy  and  sclerosis  of  the  right  hippocampus 
and  portion  of  the  neighbouring  cortex,  without  other  cerebral  lesion. 

The  second  case  related  by  Clans  (All.  Zeitsch.  fiir  Psychiat.  1878, 
p.  335),  was  a  case  of  cerebro- spinal  sclerosis,  in  which  there  were 
paresthesia  and  impaired  sensibility  in  the  upper  and  lower 
extremity  and  trunk.  On  section,  along  with  other  scleroses,  there 
was  marked  sclerosis  in  both  hippocampi.  -p  Ferrier 


BRAIN. 

OCTOBER,  1880. 

#ri0hral  Articles. 
OPTICAL  ILLUSIONS  OF  MOTION. 

BY   SILVANUS   P.   THOMPSON,   B.A.,   D.SC. 
Professor  of  Experimental  Physics,  University  College,  Bristol. 

There  are  frequent  occasions  of  conflict  between  the  re- 
ceptive faculties  of  the  senses  and  the  reflective  faculties 
of  the  intellect,  occasions  on  which  the  mind,  prejudging 
of  the  sensation  received,  assigns  it  to  a  non-existent  cause. 
Of  all  the  senses  none  is  more  frequently  the  seat  of  such 
deceptive  judgments  than  that  of  sight ;  and  in  the  science 
of  Physiological  Optics  a  very  considerable  share  of  atten- 
tion is  claimed  by  optical  illusions.  For  the  purposes  of 
convenience,  we  may  draw  a  distinction  between  these  illusions, 
which  are  the  direct  result  of  certain  properties  or  imper- 
fections of  the  eye  as  an  optical  instrument,  and  those  which 
arise  from  obliquities  of  judgment  in  interpreting  the  sensa- 
tions optically  impressed  upon  the  retina  of  the  eye.  In 
practice,  however,  it  is  almost  impossible  to  draw  a  hard-and- 
fast  line  between  the  two  classes  of  illusions,  almost  all- 
partaking  of  both  characters.  Thus,  for  example,  it  has  lately 
been  shown  that  we  habitually  draw  geometrical  forms  too 
large  in  the  horizontal  dimension  as  compared  with  their 
vertical  dimension ;  we  draw  oblate  ellipses  where  we  intend 
to  draw  circles ;  the  explanation  of  this  being  that  with  our 
two  eyes  we  really  see  spheres  as  oblate  ellipses.  Here  is,  in 
VOL.  III.  u 


290  OPTICAL  ILLUSIONS  OP  MOTION. 

fact,  an  illusion  of  pure  association — yet  based  upon  the  facts 
of  physical  and  physiological  optics.  So,  again,  certain 
inequalities  in  the  curvature  of  the  lenses  of  the  eye,  pro- 
ducing the  optical  defect  of  astigmatism,  cause  objects  that 
are  horizontal  in  position  to  form  images  at  shorter  (or  longer 
as  the  case  may  be)  distances  from  the  eye  than  the  images 
of  vertical  objects ;  the  result  being  that,  unless  the  defect  is 
corrected  by  suitable  lenses,  vertical  and  horizontal  objects 
(such  as  the  bars  of  a  window)  do  not  appear  to  be  at  the 
same  distance  from  the  observer,  though  really  equally  remote. 
This  would,  at  first  sight,  appear  to  be  a  purely  physical 
illusion,  and  not  psychological.  Nevertheless,  a  little  con- 
sideration will  show  that  since  our  perception  of  distance  is 
a  psychological  factor  in  the  case,  and  that  this  perception  is 
based  in  part  upon  the  muscular  sensations  of  adjustment  of 
the  lenses  of  the  eye  to  exact  focus,  the  illusion  is  one  which 
has  a  psychological  as  well  as  a  physical  raison  d'etre.  Again, 
take  some  illusions  ordinarily  supposed  to  be  one  purely  of 
mental  association :  the  common  illusion  of  every  day  that  the 
sun  or  moon  when  a  few  degrees  from  the  horizon  looks 
larger  than  when  high  in  the  sky,  appears  at  first  sight  to  be 
due  simply  to  the  fact  that  when  the  orb  is  near  the  horizon 
the  distant  objects  upon  that  horizon  whose  size  we  know,  or 
can  judge  of,  appear  relatively  small,  and  the  sun's  disc 
relatively  large — in  fact,  that  the  illusion  is  one  purely  of 
association  of  ideas.  Nevertheless,  when  we  look  a  little 
closer  into  the  matter,  we  find  that  our  simplest  conceptions 
of  angular  or  apparent  magnitude  are  very  closely  bound  up 
with,  if  not  directly  due  to,  the  sensations  of  muscular  fatigue 
in  moving  the  eyeball  or  head  so  as  to  bring  the  successive 
parts  of  the  object  into  the  centre  of  vision. 

Hence,  although  optical  illusions  are  of  many  diverse 
•kinds — illusions  of  colour,  illusions  of  form,  illusions  of  size, 
illusions  of  distance,  illusions  of  solidity,  and  illusions  of 
motion — they  have  all  to  be  considered  from  the  twofold 
standpoint,  the  purely  optical  and  the  psychological. 

For  some  months  the  writer  of  this  article  was  engaged  upon 
a  study  of  one  set  of  optical  illusions,  namely,  the  illusions  of 
motion,  and  a  number  of  observations,  collected  at  intervals 


OPTICAL   ILLUSIONS   OF   MOTION.  291 

over  several  years,  have  been  added  by  him  to  the  stock  of 
knowledge  previously  gleaned  by  Brewster,  Wheatstone, 
Faraday,  Plateau  and  others.  Brewster  made  a  number  of 
observations  in  the  early  days  of  railways  on  the  various 
illusions  which  can  be  found  by  watching  objects  from  a 
moving  train ;  Wheatstone  investigated  a  curious  case  of 
apparent  fluttering  motion  at  the  border  of  two  brightly 
illuminated  coloured  surfaces — due  probably  to  the  attempt  of 
the  unachromatic  eye  to  obtain  fruitlessly  a  distinct  focus  of 
the  border  line  between  the  unequally  refrangible  colours — 
known  as  the  illusion  of  the  "  Fluttering  Hearts ;  "  Faraday 
investigated  the  illusions  produced  by  intermittent  views  of 
moving  objects,  since  developed  in  the  Phenakistiscope  and 
the  Zoetrope,  and  kindred  toys,  and  due  to  persistence  of 
visual  impressions.  Brewster,  moreover,  drew  attention  to  the 
existence  of  another  class  of  illusions — illusions  of  subjective 
complementary  motion — the  typical  case  of  which  occurs 
also  in  railway  travelling.  After  looking  out  of  the  window 
at  the  pebbles  and  other  objects  lying  beside  the  line,  as  they 
pass  before  the  eyes,  let  the  eyes  be  closed  suddenly,  when 
there  will  at  once  be  perceived  an  apparent  motion  in  the 
opposite*  sense,  undistinguishable  forms  and  patches  of  light 
seeming  to  rush  past  the  blank  field.  This  was  recorded  by 
Sir  David  in  1848,  and  the  phenomenon  was  referred  by  him 
to  a  subjective  complementary  motion  going  on  simultaneously, 
and  so  causing  a  compensation  of  the  impressions  moving  over 
the  retina.  A  kindred  phenomenon  had  been  even  earlier 
noted  by  E.  Addams,  who,  in  1834,  narrated  how,  after  looking 
for  some  time  at  a  waterfall  and  then  at  the  waterworn-rocks 
immediately  contiguous,  he  saw  the  rocky  surface  as  if  in 
motion  upwards  with  an  apparent  velocity  equal  to  that  of 
the  descending  water.  This  he  ascribed  to  an  unconscious 
slipping  of  the  inferior  and  superior  recti  muscles  of  the  eye- 
balls, which  he  thought  occurred  while  watching  the  falling 
water,  and  which  he  supposed  to  continue  unconsciously  after 
the  gaze  had  been  transferred  to  stationary  objects.  This 
explanation  differs  from  the  one  offered  by  Brewster,  namely, 
that  there  was  a  subjective  opposite  movement  going  on 
simultaneously,  so  causing  a  compensation  of  the  impressions 

u  2 


292 


OPTICAL   ILLUSIONS   OF   MOTION. 


moving  over  the  retina.  Brewster's  hypothesis  is,  indeed, 
extremely  vague,  and  is  neither  physical  nor  psychological  in 
any  exact  sense.  If  understood  physically,  it  means  that 
there  is  actually  motion  in  the  retina  itself,  which  is  hardly 
conceivable,  since  the  structure  of  the  rods  and  cones  almost 
precludes  even  any  idea  of  vibration,  or  of  propagation  of  waves 
of  motion  by  vibration,  much  less  any  movements  of  them  as  a 
whole.  And,  if  the  explanation  is  intended  as  a  psychological 
one,  something  further  is  needful  before  the  principle  of  com- 
pensation here  laid  down  could  become  intelligible. 

The  first  experiments  made  by  the  writer  of  this  article 
upon  illusions  of  motion  arose  from  a  casual  observation  in 
1876.  He  had  been  preparing,  for  the  purpose  of  testing 
astigmatism,  a  set  of  concentric  circles  in  black  and  white,  such 
as  those  shown  in  Fig.  1.     Happening  to  shake  the  sheet  on 


Fig.  I. 

which  the  circles  were  drawn,  he  noticed  an  apparent  motion  of 
rotation  to  be  set  up.  The  illusion  is-  easily  produced  by 
imparting  to  the  pattern  a  slight  motion  of  the  same  character 
as  that  adopted  in  rinsing  out  a  pail,  but  with  a  very  minute 
radius  of  motion.  All  the  circles  will  appear  to  rotate  with  the 
same   angular  velocity  as  that  imparted.     Now  undoubtedly 


OPTICAL   ILLUSIONS   OF    MOTION. 


293 


the  persistence  of  visual  impressions  has  a  good  deal  to  do 
with  the  production  of  this  illusion,  which,  by  the  way, 
succeeds  best  when  the  circles  make  from  two  to  four  turns  in 
a  second,  and  when  the  radius  of  the  imparted  motion  is  equal 
to  the  thickness  of  one  ring,  so  that  each  black  or  white  band 
is  displaced  through  a  distance  equal  to  its  own  width  in  all 
directions  successively.  Nevertheless,  the  persistence  of  visual 
impressions  will  not  explain  all  the  facts  of  this  curious 
illusion  :  for,  in  the  first  place,  it  is  found  that  for  increasing 
distances  from  the  eye  the  concentric  rings  must  be  made 
wider  if  the  illusion  is  to  succeed ;  there  being  apparently  one 
particular  magnitude  of  their  images  on  the  retinae  which 
favours  the  production  of  the  illusion.  Again,  if  two  such 
"  strobic  circles  "  (as  I  have  called  them)  are  printed  side  by 
side  on  one  card,  that  set  of  circles  seems  to  turn  most 
effectively  at  which  the  eye  is  not  looking.  On  stopping  the 
"  rinsing  motion  "  suddenly,  there  appears  to  be,  for  an  instant, 
a  reverse  motion.  Finally,  if  a  set  of  circles  is  "rotated" 
while  another  set  lies  motionless  within  the  field  of  view,  the 
second  set  will  appear  to  rotate  when  the  first  are  "  rotated  "  in 


Fig.  2. 


the  manner  described  above.  It  is  possible,  also,  to  have  a 
number  of  such  apparent  motions  going  on  at  once  indepen- 
dently in    one    field   of    view.      Fig.  2    shows   a    compound 


294  OPTICAL   ILLUSIONS   OF  MOTION. 

pattern,  containing  an  interior  set  of  concentric  circles  and  six 
internally-toothed  wheels.  When  a  very  minute  "rinsing" 
motion  is  imparted  to  this  figure,  the  circles  appear  to  whirl 
round  while  the  toothed- wheels  work  slowly  backwards,  moving 
through  one  tooth  while  the  circles  whirl  round  once.  Here 
again  persistence  of  vision  is  concerned —  but  not  exclusively. 

Dr.  Emile  Javal,  the  able  director  of  the  Ophthalmological 
Laboratory  of  the  Sorbonne,  has  recently  advanced  an  expla- 
nation of  these  illusions  different  from  that  adopted  by  the 
writer,  and  in  substance  identical  with  that  advanced  by 
R.  Addams  in  the  case  of  the  waterfall  illusion.  He  avers 
that  the  eye,  in  order  to  observe  a  movement,  follows  the 
moving  body  for  an  instant  and  then  suddenly  slips  back ; 
that  this  oscillation,  frequently  repeated,  is  associated  with  a 
sensation  of  motion  in  the  particular  direction  in  question  ; 
and  that  when  the  eye  is  subsequently  directed  to  a  stationary 
object  it  continues  the  habit  of  thus  oscillating,  causing  the 
observer  to  attribute  to  the  object  a  velocity  of  opposite  sign 
to  that  just  observed.  M.  Javal  alleges  in  support  of  this 
view  the  appearance  presented  in  the  ophthalmoscope  of  the 
retina  of  a  person  affected  with  nystagmus.  This  affection 
consists  in  continual  rapid  involuntary  movements  to  and  fro 
of  the  eye.  The  retina,  under  these  circumstances,  appears  to 
be  animated  with  a  vibratory  motion  which  M.  Javal  declares 
to  be  identical  in  character  with  the  apparent  movements  of 
the  circles.  In  another  place,  M.  Javal  has  endeavoured  to 
prove  that  the  interior  and  exterior  recti  muscles  of  the  eye- 
ball are  more  prone  to  this  slipping  than  are  the  superior  and 
inferior  recti,  and  that  these  illusions  of  complementary  motion 
succeed  better  for  motions  in  a  horizontal  sense  than  for 
vertical  and  oblique  motions.  My  own  experience,  and  that 
of  other  observers,  admits  of  no  such  conclusion  being  drawn. 

An  experiment  of  Brewster's,  which  the  writer  tried  without 
knowing  at  the  time  that  Brewster  had  employed  it, !  has  an 
important  bearing  on  the  muscular-slipping  theory.     A  disc 

1  The  same  experiment  was  also  tried  by  my  friend  J.  Aitken,  Esq.,  of  Darroch, 
Falkirk,  who  independently  observed  the  phenomenon  described  by  Addams,  and 
who  has  also  communicated  to  the  Royal  Society  of  Edinburgh  a  number  of 
experiments  on  kindred  illusions. 


OPTICAL   ILLUSIONS   OF   MOTION. 


295 


marked  out  into  black  and  white  sectors,  as  in  Fig.  3,  was 
caused  to  rotate  at  about  one  revolution  per  second,  so  that 
the  separate  sensations  of  black  and  white  were  not  confused. 
The  eye  was  steadily  directed  for  twenty  or  thirty  seconds  at 
the  central  point,  and  then  the  gaze  was  suddenly  turned  upon 
some  fixed  objects,  or  at  a  distant  landscape.  For  two  or 
three  seconds  a  hazy  rotation  is  noticed  at  the  centre  of  the 
field  of  vision.  Now  if  the  muscular-slipping  theory  holds 
good,  the  complementary  movement  of  rotation  must  be  due 
to  a  slipping  of  the  whole  of  the  muscles  of  the  eyeball,  and 
would  affect  objects  all  over  the  field  of  vision  with  an  equal 


Fig.  3. 


Fig.  4. 


angular  velocity.  This  is  not  the  case,  the  apparent  com- 
plementary rotation  being  confined  to  the  central  field,  and 
with  apparent  angular  velocities  increasing  toward  the  centre 
of  vision.  Furthermore,  I  have  arranged  two  such  discs  so 
that  they  could  be  simultaneously  in  the  field  of  view  while 
rotating  in  opposite  directions.  When  the  gaze  was  directed 
first  at  a  point  between  them  and  then  at  fixed  objects,  there 
appeared  to  be  two  portions  of  the  field  of  view  rotating,  and 
animated  with  rotations  in  opposed  senses.  Clearly  the  eye 
cannot  slip  round  in  opposite  directions  at  the  same  time.  In 
all  these  illusions,  moreover,  it  is  found  that  this  illusory 
complementary  motion  only  occurs  over  limited  parts  of  the 
field  of  view — namely,  those  which  correspond  to  the  portions 
of  the  retina  which  previously  received  the  moving  images. 
Thus,  if  a  waterfall  be  looked  at — as  in  Addams's  observation — 


296  •        OPTICAL   ILLUSIONS  OF   MOTION. 

the  upward  illusory  after-motion  is  confined  to  a  vertical 
streak  across  the  field  of  vision.  This  fact  alone  is  sufficient 
to  negative  the  theory  of  muscular  slip. 

The  final  test  to  which  I  have  appealed  is,  if  possible,  even 
more  conclusive.  It  is  probably  a  familiar  observation  that 
the  end  of  the  last  carriage  of  a  retreating  railway  train 
appears  to  shrink  down  smaller  and  smaller  as  it  subtends  a 
decreasing  angular  magnitude  in  the  field  of  view.  After 
looking  at  this  motion  for  a  sufficient  number  of  seconds  to 
fatigue  the  eye,  stationary  objects  appear  to  be  expanding. 
To  produce  this  illusion  more  effectually,  I  take  a  disc  like 
that  shown  in  Fig.  4  (the  figure  is  quarter  actual  size),  marked 
out  in  spirals  of  white  and  black.  If  this  is  slowly  rotated — 
say  at  about  one  revolution  in  two  seconds — the  whole  pattern 
appears  either  to  be  running  into,  or  running  out  of,  the  centre 
of  the  disc :  there  is  a  motion  of  convergence  or  divergence, 
according  to  the  sense  of  the  rotation.  Let  the  disc  be  turned 
so  as  to  cause  an  apparent  convergence  from  all  sides  to  the 
centre,  and  let  the  eye  steadily  watch  the  centre  for  about  a 
minute,  or  until  the  fatigue  becomes  almost  unendurable. 
Then  look  at  any  fixed  object — the  pattern  of  the  wall-paper,  or 
the  dial  of  a  clock — the  object  so  regarded  will  for  some  two, 
or  three,  or  more  seconds,  appear  to  be  expanding  from  the 
centre  outwards.  The  effect  is  still  more  startling  if  the 
object  thus  viewed  be  the  face  of  a  familiar  friend.  It  is 
quite  evident  that  the  eyeball  cannot  slip  in  all  directions  at 
once. 

I  have  therefore  somewhat  reluctantly  been  led  to  propound 
an  explanation  for  these  illusions,  embodying  the  theory  of 
them  in  an  empirical  law  based  upon  the  physical  fact  of 
retinal  fatigue,  and  on  the  psychological  fact  of  association  of 
contrasts.  It  is  as  follows : — The  retina  ceases  to  perceive  as  a 
motion  a  steady  succession  of  images  that  pass  over  a  particular 
region  for  a  sufficient  time  to  induce  fatigue  ;  and  on  a  portion  of 
the  retina  so  affected,  the  image  of  a  body  not  in  motion  appears 
by  contrast  to  be  moving  in  a  complementary  direction.  This 
law  is  precisely  similar  to  that  of  the  complementary  sub- 
jective colours  seen  after  fatiguing  the  retina  by  the  image  of 
a  coloured  body.     Similar  laws  of  physico-psychological  after- 


OPTICAL   ILLUSIONS   OF   MOTION.  297 

effects  are  abundant.  A  steady  sound  of  one  constant  pitch 
ceases  to  be  heard  until  we  become  aware  of  it  by  its  cessation. 
A  steady  light  of  one  colour,  such  as  the  yellow  light  of  gas- 
flames,  ceases  to  be  noticed  as  a  yellow  light  until  some  other 
colour-sensation  break  the  illusion.  The  same  is  true  of  smells, 
of  tastes,  of  the  sensations  of  temperature,  of  the  sensation  of 
rotation  after  a  waltz,  and  of  many  others.  All  these  are  pro- 
bably only  different  instances  of  the  operation  of  some  much 
more  general  physico-psychological  law.  It  is  quite  consonant 
with  these  kindred  phenomena  that  when  any  region  of  the 
retina  is  affected  by  an  image  of  objects  moving  steadily  across 
the  corresponding  portion  of  the  field  of  view  in  any  given 
direction,  that  portion  of  the  retina  gradually  loses  conscious- 
ness of  the  motion,  and  perceives  it  only  as  a  steady  sensation, 
or  as  one  of  approximate  rest.  When,  however,  an  object 
really  at  rest  is  looked  at,  the  associative  faculty  seizes  upon  the 
contrast  in  the  sensations  affecting  that  region,  and  interprets 
the  new  sensation  by  imputing  a  motion  in  the  opposite  sense 
to  the  objects  occupying  the  corresponding  portion  of  the 
field  of  vision.  I  have  proposed  to  give  to  the  empirical  law 
expressing  these  matters  the  name  of  the  law  of  subjective 
complementary  motion. 

It  is  impossible  to  quit  the  subject  without  pointing  out  two 
lines  of  thought  suggested  by  that  which  has  been  advanced. 

Firstly,  it  is  conceivable  that  the  explanation  here  pro- 
pounded may  at  some  future  time  be  superseded  by  a  better 
hypothesis  of  a  more  purely  physical  character.  Suppose,  for 
example,  that  it  could  be  shown — what  I  have  reason  to 
suspect,  but  have  been  foiled  in  all  attempts  to  prove  in  any 
experimental  fashion — that  the  eye  has  the  power  of  altering 
at  will  the  actual  size  of  the  retinal  images  by  a  double 
muscular  adjustment  between  the  magnifying  power  of  the 
lenses  of  the  eye  and  the  distance  of  their  equivalent  optical 
centre  from  the  surface  of  the  retina,  such  a  fact,  once 
established,  would  entirely  cut  away  the  significance  of  my 
crucial  test  with  the  rotating  spirals ;  and  the  apparent  ex- 
pansions and  contractions  of  objects  would  be  merely  due  to 
the  continuous  attempts  of  the  eye  to  retain  the  retinal  images 
of  one  constant  size.     If  this  were  so  (though  I  have  failed  in 


298  OPTICAL   ILLUSIONS  OF  MOTION. 

every  kind  of  attempt  to  devise  some  satisfactory  test),  it 
might  also  explain  one  little  matter  that  is  still' very  mys- 
terious and  unexplainable,  namely,  that  in  these  illusions  of 
expansion  and  contraction  the  changes  of  apparent  magnitude 
often  appear  to  take  place  by  discontinuous  jumps  rather  than 
by  steady  motions. 

Secondly,  it  is  found  that  these  different  illusions  affect 
different  individuals  with  very  different  degrees  of  success, 
some  persons  being  much  more  sensitive  than  others  to  the 
after-workings  of  the  subjective  motion ;  and,  indeed,  there 
are  individuals  in  whose  case  it  is  almost  impossible  to  produce 
the  illusions.  Doubtless  some  of  these  differences  may  be 
accoimted  for  by  defects  of  vision,  astigmatism,  achromatopsy, 
myopy,  and  the  like.  But  there  is  also  a  time-element  in  the 
case  which  varies  very  greatly  with  individuals,  and  even 
varies  with  the  nervous  states  of  the  same  individual.  And 
this  suggests  the  further  thought  that  a  careful  comparison  of 
individuals  relatively  to  their  illusion-capacity  might  elicit 
some  interesting  and  perhaps  valuable  facts  concerning  the 
relation  between  the  states  of  brain-organisation  and  the 
sensations  of  the  more  highly  specialised  organs  of  sense. 


ON  SOME  POINTS  IN  THE  DIAGNOSIS  AND 
TREATMENT  OF  BRAIN  DISEASE. 

BY   JULIUS   ALTHAUS,   M.D. 
Senior  Physician  to  the  Hospital  for  Epilepsy  and  Paralysis,  Regent's  Park. 

It  is  a  singular  fact  that,  while  pathological  changes  in  certain 
areas  of  the  cerebral  substance  invariably  cause  definite  groups 
of  symptoms,  and  can  therefore,  unless  the  patient  succumb 
rapidly,  be  diagnosed  with  great  certainty  during  life,  on  the 
other  hand,  coarse  lesions  may  be  discovered  after  death  in 
important  parts  of  the  brain,  without  having  manifested  their 
presence  by  any  apparent  deviation  from  health  during  the 
patient's  lifetime.  There  are  those  who  contend  that  this 
latter  event  only  occurs  in  slowly-growing  tumours,  which  do 
not  so  much  destroy  the  parts  the  sphere  of  which  they  invade 
as  push  them  aside,  and  which  increase  so  gradually  in  bulk 
as  to  give  the  structures  concerned  sufficient  time  to  adapt 
themselves  to  altered  circumstances,  and  to  preserve  their 
functions,  however  much  their  normal  situation  and  nutrition 
may  be  interfered  with.  This  opinion,  however  plausible  at 
first  sight,  appears  to  us  untenable,  for  we  shall  have  to  show 
that  almost  any  morbid  processes,  such  as  haemorrhage,  soften- 
ing, abscess,  atrophy,  tubercle,  as  well  as  the  various  forms  of 
tumours  habitually  encountered  in  the  brain-substance,  such  as 
glioma,  sarcoma,  osteoma,  &c,  may  exist  in  important  localities 
without  giving  rise  to  those  special  symptoms  which  we  seem 
almost  to  have  a  right  to  expect  under  those  circumstances. 
On  the  other  hand,  the  reverse  of  this  may  be  observed  clini- 
cally in  numerous  cases,  viz.,  that  grave  symptoms  showing  con- 
siderable alteration  of  brain-function  exist,  in  which  neverthe- 
less coarse  lesions  are  eventually  shown  to  be  absent,  inasmuch 
as   these   symptoms    yield   completely   to   certain   modes  of 


300  ON   SOME   POINTS   IN   THE   DIAGNOSIS   AND 

treatment  which  could  not,  with  any  show  of  reason,  be  supposed 
to  have  a  curative  influence  upon  such  occurrences  as  haemor- 
rhage, softening,  or  tumour.  Then  again  patients  die  occasion- 
ally with  the  symptoms  of  ingravescent  apoplexy,  and  yet  no 
haemorrhage  or  other  serious  cerebral  lesion  is  discovered  on 
inspection. 

By  far  the  commonest  form  of  brain  disease  to  be  met  with 
in  practice  is  hemiplegia,  which  comes  on  suddenly,  affects  the 
lower  branches  of  the  portio  dura  and  the  corresponding  upper 
and  lower  extremity,  is  followed  by  late  rigidity,  and  remains 
more  or  less  permanent.  In  such  cases  we  can  say  with  a  great 
degree  of  certainty  that  the  opposite  corpus  striatum,  and  more 
particularly  its  internal  capsule,  must  have  been  injured.  It 
is  true  that  a  similar  group  of  symptoms  may  be  observed  (a.) 
in  disease  of  the  upper  portion  of  the  pons  Varolii ;  (b.)  of  the 
crus  cerebri ;  (c.)  of  the  centrum  ovale  ;  and  (d.)  of  the  central 
convolutions  and  the  paracentral  lobule  of  the  cineritious 
substance  of  the  hemispheres ;  yet  we  know  by  experience  that 
haemorrhage  and  softening,  being  the  most  frequent  causes  of 
the  ordinary  form  of  hemiplegia,  have  a  special  predilection 
for  the  corpus  striatum,  which  receives  its  blood -supply  chiefly 
from  the  lenticulo-striated  arteries.  These  vessels,  being  the 
immediate  continuation  of  the  middle  cerebral,  and  therefore 
the  carotid  artery,  are  more  than  others  exposed  to  direct 
cardiac  pressure,  and  therefore  more  liable  to  aneurismal 
dilatation  and  rupture.  As  embola  are  for  the  same  reason 
more  liable  to  be  carried  into  them  than  into  other  vessels, 
necro-biotic  softening  from  embolism  is  more  frequent  there 
than  elsewhere ;  while  thrombosis  has  no  particular  affinity  to 
the  vessels  supplying  the  corpus  striatum,  and  softening  from 
thrombosis  therefore  occurs  elsewhere  as  much  as  there. 

With  regard  to  hemiplegia  from  disease  of  the  other  brain- 
portions  just  mentioned,  it  is  found  that : 

(a.)  Lesions  of  the  pons  Varolii  only  rarely  cause  that  form 
of  hemiplegia  of  which  we  have  just  spoken,  but  almost  in- 
variably a  motor  paralysis  which  is  known  as  alternate  hemi- 
plegia of  the  extremities  and  certain  cranial  nerves,  more 
especially  the  sixth,  the  portio  dura  and  the  hypoglossus,  which 
latter  are  paralysed  on  the  side  of  the  lesion,  while  the  ex- 


TREATMENT   OF   BRAIN   DISEASE.  301 

tremities  are  paralysed  on  the  opposite  side.  Moreover 
anarthria  or  dysarthria  is  generally  observed  at  the  same  time, 
and  difficulty  of  deglutition,  impairment  of  the  circulation  and 
respiration,  and  anaesthesia  of  the  paralysed  side  of  the  face, 
may  be  found.  The  presence  or  absence  of  all,  or  some  of  these 
symptoms,  will  therefore  enable  us  to  pronounce  for  or  against 
a  pontine  lesion. 

(b.)  Disease  of  the  crus  cerebri  may  cause  crossed  hemi- 
plegia of  the  lower  branches  of  the  portio  dura,  the  hypo- 
glossus,  and  the  corresponding  upper  and  lower  extremity ; 
yet  in  some  of  these  cases  the  fifth,  and  in  more,  the  third 
nerve  will  be  found  paralysed,  the  latter  suffering  alternately 
with  the  other  nerves,  i.e.  on  the  side  of  the  lesion,  while  the 
other  cranial  nerves,  together  with  the  extremities,  are  para- 
lysed on  the  side  opposite  to  the  lesion.  Such  unusual  symp- 
toms as  third-  and  fifth-nerve  paralysis,  in  connection  with 
hemiplegia,  are  therefore  quite  sufficient  to  guide  us  in  our 
diagnosis  of  such  cases. 

(c.)  Disease  of  the  centrum  ovale  cannot  at  present  be 
diagnosed  with  any  degree  of  probability.  This  structure  may 
be  extensively  diseased  without  giving  rise  to  any  symptoms 
whatever ;  and  where  symptoms  are  present,  we  find  crossed 
paralysis,  either  in  the  form  of  hemiplegia  or  monoplegia, 
leading  us  to  suspect  at  first  sight  disease  of  the  corpus 
striatum  or  certain  portions  of  the  cortex.  Pitres  has  attached 
importance  to  the  presence  of  unilateral  convulsions,  affecting 
the  paralysed  parts  only,  as  distinctive  of  disease  of  the  centrum 
ovale ;  but  he  has  not  succeeded  in  showing  that  in  these  cases 
there  was  not  likewise  irritation  of  certain  portions  of  the 
cortical  substance,  which  we  know  to  give  rise  to  this  class  of 
convulsions. 

(d.)  Disease  of  the  cortex  does,  in  exceptional  cases,  give 
rise  to  the  ordinary  form  of  hemiplegia  such  as  we  are  in  the 
habit  of  associating  with  corpus  striatum  disease  ;  yet,  where 
the  antero-parietal  or  postero-parietal  gyrus,  or  the  paracentral 
lobule,  or  all  these  parts  together  are  affected,  the  hemiplegia 
is  generally  "  dissociated "  or  piecemeal ;  that  is,  we  find 
paralysis  of  the  arm  and  leg  without  any  affection  of  cranial 
nerves  ;  or  paralysis  of  the  arm  alone  ;  or  of  the  arm  and  the 


302  ON  SOME  POINTS  IN  THE  DIAGNOSIS  AND 

portio  dura ;  or  there  is  ptosis,  and  paralysis  of  the  portio  dura 
and  hypoglossus,  without  affection  of  the  extremities ;  besides 
which  there  may  be  certain  forms  of  anaesthesia.  Signs  of 
motor  irritation  are  the  rule,  either  previous  to,  or  after  the 
occurrence  of  the  paralysis,  and  appear  as  chronic  spasms 
always  affecting  the  same  sets  of  muscles  in  one  side  of  the 
face,  or  the  corresponding  extremities,  and  which  often  merge 
into  general  epileptiform'  convulsions. 

Amongst  those  portions  of  the  brain  which  may  be  found 
extensively  diseased  without  there  having  been  any  symptoms 
during  life,  we  would  hardly  expect  to  find  the  medulla  oblongata, 
seeing  the  extreme  physiological  importance  of  the  numerous 
centres  which  are  there  crowded  together  in  a  small  compass. 
We  know  injury  to  the  medulla  to  be  immediately  fatal ;  and 
any  sudden  interference  with  its  structure,  such  as  the  rupture 
of  a  miliary  aneurism  and  consequent  effusion  of  blood  into  it, 
is  likewise  incompatible  with  life.  Death  is  under  those 
circumstances  so  sudden  that  one  is  inclined  to  attribute  it  to 
heart-disease  ("  apoplexie  foudroyante  "  of  the  French  authors). 
Such  cases  are  very  rare;  and  embolism  of  the  vertebral 
artery  leading  to  necro-biotic  softening  of  the  medulla  is,  for 
anatomical  reasons,  even  more  rare.  On  the  other  hand, 
thrombosis  from  disease  of  that  blood-vessel  is  somewhat  more 
frequent,  but  does  not  kill  nearly  with  the  same  rapidity  as 
haemorrhage ;  for  as  the  artery  is  only  gradually  occluded,  the 
patient  may  survive  for  a  few  days,  and  present  symptoms  of 
apoplectiform  bulbar  paralysis,  viz.,  dysarthria,  dysphagia, 
paralysis  of  the  soft  palate  and  stertorous  breathing,  hoarse- 
ness or  complete  aphonia,  hiccough,  cough,  vomiting,  and 
irregular  respiration  and  circulation  leading  to  cyanosis. 
This  cluster  of  symptoms  coming  on  while  consciousness 
remains  intact,  is  highly  characteristic  for  the  lesion  of  which 
we  have  spoken.  It  is  true  that  Charcot  and  Lepine  have 
drawn  attention  to  a  somewhat  similar  concourse  of  symptoms 
arising  from  certain  cortical  lesions ;  but  in  the  latter  there  is 
rarely  dyspnoea  or  cyanosis,  and  the  symptom  of  aphonia  occurs 
in  no  cerebral  affection  whatever  except  one  of  the  medulla,  so 
that  by  this  sign  alone  the  diagnosis  may  be  rendered  certain. 

While  therefore  in  sudden  lesions  of  the  medulla,  such  as 


TREATMENT   OP  BRAIN   DISEASE.  '•  303 

haemorrhage,  or  apoplectiform  softening  from  thrombosis, 
symptoms  of  the  utmost  gravity  are  observed,  we  find,  on  the 
other  hand,  that  this  complex  organ  will  apparently  not  resent 
disease  coming  on  in  a  more  insidious  manner.  Dr.  Wilks  has 
recorded  the  case  of  a  girl  who  was  admitted  into  Guy's 
Hospital,  complaining  of  occipital  headache.  There  being  no 
other  symptoms,  the  pain  was  thought  functional,  possibly 
hysterical.  Two  days  afterwards  she  was  found  dying,  respira- 
tion having  suddenly  become  arrested.  As  the  heart's  action 
continued,  artificial  respiration  was  had  recourse  to  for  eight 
hours  ;  and  the  heart  continued  to  beat  for  twenty-five  minutes 
after  the  cessation  of  these  therapeutical  efforts.  At  the  post- 
mortem examination  a  glioma  was  found  in  the  medulla  infil- 
trating and  encroaching  on  all  the  important  centres,  including 
the  fourth  ventricle.  Other  cases  in  which  there  was  an 
almost  entire  absence  of  symptoms,  have  been  seen  by  Ollivier, 
Louis,  and  Schulz.  In  the  latter 's,  there  was  a  glioma  occu- 
pying almost  the  entire  thickness  of  the  medulla,  of  which 
only  a  small  zone  of  nervous  matter  remained.  There  was  also 
sclerosis  of  the  lateral  columns  of  the  spinal  cord,  which  during 
life  had  caused  the  symptoms  of  spastic  paralysis ;  but  no  sign 
referable  to  the  medullary  disease  had  been  noticed. 

Next  in  vital  importance  to  the  medulla  oblongata  comes  the 
pons  Varolii,  disease  of  which  is  much  more  frequent  than  that 
of  the  medulla.  Haemorrhage  is  almost  invariably  fatal,  but  not 
with  such  extreme  suddenness  as  when  the  effusion  takes  place 
into  the  medulla,  two  or  three  hours  generally  elapsing 
between  the  first  onset  of  the  symptoms  and  death ;  yet  where 
the  clot  is  large,  and  presses  considerably  on  the  medulla,  the 
fatal  issue  may  be  more  sudden.  Embolism  of  the  basilar 
artery,  which  would  lead  to  necro-biotic  softening  of  the  pons, 
does  not  occur  for  anatomical  reasons ;  while  thrombosis  of  that 
vessel,  more  especially  in  syphilitic  subjects,  is  by  no  means 
rare.  According  to  the  extent  of  the  thrombosis  the  symptoms 
may  vary  considerably,  which  need  not  surprise  us,  seeing  the 
number  of  centres  and  conducting  paths  which  exist  in  such 
abundance  in  this  most  complex  structure.  There  are  no  cases 
of  haemorrhage  or  softening  on  record  in  which  not  some  at 
least  of  the  symptoms  of  alternate  paralysis  were  present,  viz., 


304  ON   SOME   POINTS   IN    THE   DIAGNOSIS   AND 

crossed  hemiplegia  of  the  limbs,  and  equilateral  paralysis  of 
the  mouth,  divergent  strabismus,  and  anaesthesia  of  one  side 
of  the  face,  as  well  as  dysarthria. 

It  is,  however,  different  with  tumours  which,  if  growing  very 
slowly,  may  become  developed  without  causing  any  symptoms, 
and  even  gradually  attain  a  considerable  size.  Such  cases 
have  been  recorded  by  Hallopeau,  Laborde,  Henoch,  and  others. 
In  Laborde's  case  there  was  a  tubercle  of  the  size  of  a  filbert 
in  the  centre  of  the  pons ;  and  in  Hallopeau's  there  was  an 
area  of  tubercular  disease  in  the  central  portion  of  the  organ, 
which  measured  1\  centimetres  in  its  largest  diameter.  These 
cases  are  however  exceptional,  since  generally  speaking  the 
symptoms  in  pontine  tumours  are  of  a  most  varied  description, 
consisting  in  the  sphere  of  motion  of  paralysis  and  convulsions, 
muscular  rigidity,  lock-jaw,  nystagmus,  pendulum-like  move- 
ments of  arm  and  leg ;  in  the  sphere  of  sensation  of  pain  and  of 
anaesthesia,  which  affects  the  face  and  the  extremities,  the 
affection  being  crossed  in  the  latter ;  to  which  are  sometimes 
added  certain  vaso-motor  and  trophic  phenomena. 

There  is  no  portion  of  the  brain  where  the  peculiarity  which 
we  are  considering  obtains  so  frequently  and  with  all  different 
kinds  of  disease  as  the  cerebellum,  a  circumstance  which  renders 
the  diagnosis  of  cerebellar  affections  a  matter  of  peculiar  diffi- 
culty, and  sometimes  one  of  impossibility.  Not  only  tumours, 
but  haemorrhage,  softening,  abscess,  atrophy  and  tubercle,  have> 
been  discovered  by  such  observers  as  Bourneville,  Nothnagel, 
Heusinger,  and  others,  in  which  during  life  absolutely  no 
symptom  was  noticed.  In  Ebstein's  case,  almost  the  entire  left 
hemisphere  was  destroyed  by  an  osteoma ;  in  Lallement's,  there 
was  complete  atrophy  of  the  left  lateral  lobe  without  tumour, 
and  also  atrophy  of  the  right  olivary  body,  and  part  of  the 
right  corpus  striatum  ;  in  Heusinger's,  there  was  an  abscess  in 
the  right  lateral  lobe  which  was  apparently  four  or  five  months 
old ;  in  Nothnagel's,  a  cicatrix  in  the  corpus  dentatum,  which 
was  evidently  the  remains  of  old  haemorrhage,  the  patient 
having  eventually  died  of  dysentery ;  in  Mosler's  case,  an  area 
of  inflammatory  softening  in  the  nucleus  dentatus  of  the  left 
lateral  lobe  of  the  size  of  a  pigeon's  egg,  the  patient  having 
suffered  from  diabetes  and  died  of  pleurisy  without  any  symp- 


TREATMENT   OF   BRAIN   DISEASE.  305 

toms  on  the  part  of  the  nervous  system ;  while  in  Andral's 
case  (that  of  a  boy  who  died  of  pulmonary  consumption)  four 
tubercles  in  the  left  lateral  lobe  were  found,  three  of  them 
being  of  the  size  of  a  cherry  and  one  of  a  filbert.  Instances 
like  these  might  be  multiplied  indefinitely,  while  in  others 
again  a  variety  of  symptoms  has  been  observed.  As  a  general 
result  it  may  be  stated  (a.)  that  there  are  no  symptoms  where 
the  disease  is  localised  in  one  lateral  lobe,  and  where  it  does 
not  produce  pressure  on  neighbouring  parts,  such  as  the  middle 
lobe,  the  pons  Varolii,  the  medulla,  or  the  corpora  quadri- 
gemina ;  and  disease  of  one  of  the  lateral  lobes  is  therefore  as 
a  rule  impossible  to  recognise  during  life ;  (6.)  that  symptoms 
of  a  definite  character  occur  almost  invariably  where  the 
middle  lobe  is  affected ;  (e.)  that  the  principal  symptoms  are  the 
"  reeling  gait "  (cerebellar  ataxy)  and  a  peculiar  form  of  ver- 
tigo ;  and  (d.)  that  all  other  symptoms  which  have  been  noticed 
in  cerebellar  disease,  such  as  optic  neuritis,  vomiting,  certain 
forms  of  paralysis  and  convulsions,  nystagmus,  headache, 
various  kinds  of  anaesthesia,  paresthesia,  and  hypera3sthesia, 
deafness,  and  symptoms  of  mental  disturbance,  are  uncertain 
and  inconstant,  and  generally  owing  to  pressure  of  tumours 
on  distant  parts,  or  to  co-existing  disease  in  other  organs. 

Of  the  crura  cerebelli,  only  those  which  connect  the  organ 
with  the  pons  Varolii — the  middle  crura — seem  to  give  rise  to 
special  symptoms  when  diseased,  while  the  inferior  crura  which 
connect  the  cerebellum  with  the  medulla,  and  the  superior 
ones  which  link  it  with  the  optic  lobes,  may  become  diseased 
without  apparently  resenting  it.  Again,  simple  destruction  of 
the  middle  crura,  as  by  haemorrhage  or  softening,  may  pass 
unperceived,  while  irritation  of  these  parts,  chiefly  by  growing 
tumours,  causes  characteristic  appearances,  provided  the  con- 
nection between  the  crura  and  the  cerebellum  be  not  com- 
pletely destroyed.  These  consist  of  certain  forced  movements 
or  positions  of  the  body,  head  or  eyes,  over  which  the  patient 
himself  has  no  control  whatever,  and  which,  if  disturbed  by 
others,  at  once  reassert  themselves.  They  occur  sometimes  in 
a  state  of  unconsciousness  ;  and  where  the  patient  is  conscious, 
resistance  on  his  part  to  such  forced  movements  or  positions  is 
unavailing.     Sometimes  they  appear  in  the  form  of  fits,  so  that 

vol.  in.  x 


306  ON   SOME   POINTS  IN   THE   DIAGNOSIS  AND 

the  body  is  turned  right  over  in  bed  four  or  five  times  con- 
secutively, by  the  action  of  the  spinal  muscles,  the  patient 
occasionally  resisting  such  movements  by  taking  hold  of  the 
bed-clothes,  but  without  effect.  In  other  cases  the  patient 
remains  constantly  lying  on  one  side,  and  if  his  position  be 
shifted  by  the  nurse,  returns  at  once  to  the  one  previously 
assumed.  Conjugate  deviation  of  the  head  and  eyes  may  also 
occur,  or,  as  in  Nonat's  case,  one  eye  may  be  turned  outwards 
and  downwards,  while  the  other  is  directed  inwards  and  upwards. 
The  presence  or  absence  of  coma  is  of  some  importance  in  such 
cases ;  for  conjugate  deviation  of  the  head  and  eyes  is  known 
to  occur  in  haemorrhage  of  the  central  ganglia,  pons  Varolii, 
and  the  meninges,  together  with  coma,  while  in  disease  of  the 
middle  crura  it  may  occur  without  coma. 

The  crura  cerebri  are,  in  their  progress  from  the  anterior 
border  of  the  pons  Varolii  towards  the  central  ganglia,  often 
implicated  in  disease  of  the  latter,  yet  may  suffer  by  them- 
selves of  haemorrhage,  softening,  &c,  owing  to  disease  of  the 
external  posterior  optic  arteries  (Duret).  As  a  rule,  the  symp- 
toms are  well  marked,  there  being  either  crossed  paralysis  of 
the  extremities,  the  portio  dura,  and  the  hypoglossus ;  or  these 
symptoms  are  combined  with  equilateral  paralysis  of  the  third 
nerve,  thus  constituting  a  form  of  alternate  paralysis  which  is 
peculiar,  and  from  which  a  definite  conclusion  as  to  localisation 
in  the  crus  may  be  drawn;  while,  of  course,  simple  crossed 
paralysis  of  the  extremities,  the  portio  dura  and  the  hypo- 
glossus, may  be  due  to  a  variety  of  other  lesions.  The  paralysis 
of  the  third  nerve  may  be  complete,  when  there  is  ptosis, 
external  strabismus,  and  diplopia;  or  it  may  be  incomplete. 
In  either  case,  however,  the  lesion  appears  to  be  seated  in  the 
internal  portion  of  the  crus,  while  affection  of  its  external 
portion  is  more  apt  to  cause  anaesthesia  than  paralysis.  No 
local  symptoms  were  observed  in  a  case  of  Gintrac's,  where  a 
tubercle  of  considerable  size  was  found  in  the  right  crus  of 
a  boy  six  months  of  age;  and  of  Delasiauve's,  where  an 
encephaloid  growth  was  discovered  in  the  left  crus. 

Localised  softening  and  haemorrhage  do  not  appear  to  occur 
in  the  corpora  quadrigemina  or  optic  lobes,  no  doubt  owing  to 
their  deriving  their  blood-supply  from  the  posterior  cerebral 


TREATMENT   OF   BRAIN   DISEASE.  307 

arteries,  which  also  nourish  the  optic  thalami  and  other  neigh- 
bouring parts,  so  that  the  latter  are  apt  to  be  affected  simul- 
taneously. Griesinger  taught  that,  when  vision  was  normal, 
there  could  be  no  affection  of  the  optic  lobes ;  yet  cases  have 
been  recorded  by  Kohts,  Growers,  and  Steffen,  in  which  de- 
structive lesions  of  these  parts  were  unaccompanied  by  blind- 
ness. The  whole  subject  is  still  involved  in  much  obscurity, 
inasmuch  as.  tumours  may,  simply  by  causing  an  increase 
of  intra-cranial  pressure,  give  rise  to  the  choked  disc,  optic 
neuritis,  and  other  symptoms,  which  have  nothing  whatever  to 
do  with  their  localisation  in  the  optic  lobes.  Yet  it  appears 
probable  that  disease  of  the  posterior  portion,  or  the  nates,  is 
less  likely  to  cause  amaurosis  than  lesions  of  the  anterior 
portion,  or  the  testes;  while  on  the  other  hand,  palsies  of 
certain  branches  of  both  third  nerves  seem  to  speak  for 
affection  of  the  nates. 

If  there  be  obscurity  in  the  pathology  of  the  optic  lobes, 
Cimmerian  darkness  may  be  said  to  prevail  in  the  sphere  of 
the  optic  thalami,  concerning  which  the  best  observers  are  at 
this  moment  in  a  state  of  apparently  hopeless  discrepancy. 
This  is  no  doubt  owing  to  the  circumstance  that  truly  localised 
lesions,  whether  from  haemorrhage,  softening,  or  tumour,  are 
very  rare  in  these  parts,  and  that  in  most  cases  which  come 
under  observation,  extensive  pathological  alterations  co-exist 
in  important  neighbouring  structures.  In  consequence  of  this, 
the  most  fundamental  points  are  as  yet  undecided,  such,  for 
instance,  as  whether  the  optic  thalami  have  anything  to  do 
with  the  sense  of  sight  or  not,  whether  they  are  centres  of 
common  sensation  or  not,  whether  lesions  in  them  give  rise  to 
the  ordinary  form  of  hemiplegia  or  not,  &c.  One  fact,  however, 
is  certain,  viz.,  that  haemorrhage  may  occur  in  these  parts  without 
giving  rise  to  any  symptoms  at  all ;  and  Nothnagel  has  recorded 
a  case  in  which  there  was  even  bilateral  haemorrhage  in  the 
thalami  without  the  least  suspicion  of  cerebral  disease  having 
been  excited  during  life.  This  also  holds  good  for  tumours,  as 
in  Gintrac's  case  there  was  tubercle  in  both  thalami  in  a 
patient  who  had  never  shown  symptoms  of  brain-affection. 

With  regard  to  paralysis,  it  may  be  said  that  its  presence 
speaks   rather   against,   than   for,   disease  of    the    thalamus. 

x  2 


308         ON   SOME   POINTS,  ETC.,   IN  BKAIN  DISEASE. 

Complete  destruction  of  its  posterior  third  has  been  seen 
without  a  trace  of  paralysis ;  in  lesions  of  the  middle  third, 
paralysis  has  only  been  noticed  when  the  area  of  disease  was 
very  extensive,  and  may  therefore  be  inferred  to  have  exercised 
pressure  on  the  internal  capsule,  while  where  the  area  was 
small,  no  paralysis  was  present;  and  finally,  disease  of  its 
anterior  third  is  so  constantly  associated  with  destruction  of 
the  corpus  striatum,  and  more  especially  the  internal  capsule, 
that  the  hemiplegia  which  is  present  in  such  cases,  has  to  be 
referred  to  the  latter  structures.  Common  sensation  was 
formerly  believed  to  centre  in  the  thalamus  and  to  suffer  from 
its  destruction,  but  this  theory  has,  for  the  present  at  least, 
been  disposed  of  by  the  researches  of  Lafforgue.  On  the  other 
hand,  Crichton  Browne  has  rendered  it  probable  that  disease 
of  the  thalamus  causes  diminution  or  abolition  of  reflex  exci- 
tability, more  especially  in  the  upper  extremity ;  and  finally, 
certain  forms  of  motor  irritation,  such  as  hemichorea,  athetosis, 
and  tremor,  seem  to  be  connected  with  disease  in  this  part. 
Nevertheless  we  may  say  that  the  best-informed  physician 
cannot  at  present  diagnose  disease  of  the  thalamus  with  any 
degree  of  certainty. 

(To  be  continued.) 


KECUKEtENT  HEADACHES  IN  CHILDREN. 

BY   FRANCIS   WARNER,   M.D.   LOND.,   M.R.C.P. 

Assistant  Physician  to  the  London  Hospital,  and  to  the  East  London  Hospital 

for  Children. 

Headaches  are  of  such  common  occurrence  in  young  people 
that  no  physician  whose  observations  are  made  largely  among 
children,  can  fail  to  meet  with  many  cases  in  which  headache 
is  the  main  subject  of  complaint.  In  dealing  with  this  group 
of  cases  from  a  scientific  point  of  view,  it  is  evidently  necessary 
to  define  the  physical  conditions  which  may  be  taken  as  signs 
of  that  mobile  or  irritable  condition  of  the  nervous  system  in 
which  headaches  are  so  common. 

The  study  of  diseased  conditions  of  the  brain  has  been 
greatly  advanced  by  observing  the  conditions  of  the  muscles 
of  the  face,  eyes,  limbs,  trunk,  &c.  It  is  by  the  clonic  muscu- 
lar twitchings  in  chorea  that  we  know  the  brain  is  choreic  ;  it 
is  by  the  condition  of  hemiplegia  we  are  led  to  infer  that 
there  is  a  lesion  in  the  basic  ganglia  of  the  opposite  hemi- 
sphere ;  it  is  by  the  observation  of  labio-glosso-laryngeal  para- 
lysis that  we  diagnose  disease  of  the  olivary  body.  If,  then, 
we  would  conduct  our  observations  in  the  case  of  children  who 
suffer  from  recurrent  headaches  on  principles  and  lines  of  in- 
vestigation similar  to  those  which  have  led  to  important  results 
in  the  study  of  chorea,  hemiplegia,  and  other  cases  of  organic 
disease,  we  must  carefully  observe  the  condition  of  the  muscu- 
lar system  in  such  patients.  Following  upon  these  lines  of 
argument,  I  have  in  many  cases  examined  and  recorded  the 
conditions  of  muscles  supplied  by  cranial  nerves,  and  those  of 
the  upper  extremities. 

It  is  a  matter  of  common  observation  that  a  patient  may 
"  look  as  if  he  had  a  headache." 

Such  an  appearance  of  the  face  can  only  result  from  its 
colour,  form,  or  mobile  conditions,  for  these  are  its  only  distin- 
guishing characteristics. 


310  RECURRENT   HEADACHES  IN   CHILDREN. 

In  children  it  is  not  uncommon  to  have  "  the  expression  of 
headache  in  the  face ;"  so  frequently  was  it  observed,  that  I 
came  to  look  upon  it  as  a  physical  sign  of  the  condition  which 
produces  headache. 

A  face  may  be  analysed  as  to  the  three  properties  spoken 
of,  and  that  as  to  either  half  of  the  face,  or  as  to  the  upper, 
middle,  or  lower  portions.  If  either  vertical  half  of  the  face 
be  covered  in  turn  by  a  paper,  "  the  expression  of  headache  " 
is  seen  equally  on  each  side,  proving  that  the  cause  of  the  ex- 
pression is  bilaterally  symmetrical.  If  the  paper  be  held  with 
one  margin  horizontal  it  may  be  made  to  cover  in  succession, 
(1)  the  forehead  down  to  the  level  of  the  eyebrows ;  (2)  the 
parts  about  the  eyes  from  the  eyebrows  to  the  lower  margins 
of  the  orbit ;  (3)  the  parts  from  the  lower  margin  of  the  orbits 
downwards,  including  the  mouth,  cheeks,- and  alae  nasi. 

In  analysing  faces  to  see  wherein  lay  "the  expression  of 
headache,"  I  looked  at  the  faces  of  adults,  and  the  expression 
seemed  retained  as  long  as  the  parts  about  the  eyes  were  seen 
and  lost  when  the  middle  zone  was  covered,  i.e.,  this  peculiar 
facies  appeared  due  to  the  condition  of  the  parts  about  the 
orbicularis  oculi.  There  seemed  to  be  a  loss  of  tone  in  this 
muscle;  there  was  an  appearance  of  fulness  and  flabbiness 
about  the  lower  eyelid  ;  the  skin  hung  too  loose,  and  in  place 
of  falling  against  the  lower  eyelid  neatly,  as  a  convex  surface, 
it  fell  more  or  less  in  a  plane  from  the  ciliary  margin  to  the 
lower  margin  of  the  orbit.  This  condition  is  often  seen  best 
by  looking  at  the  patient's  face  in  profile.  This  condition  of 
the  parts  about  the  eye  may  often  be  seen  in  children,  unac- 
companied by  any  general  change  in  the  skin  of  the  face,  such 
as  the  flabbiness  seen  in  emphysema,  and  the  loose  inelastic 
skin  of  senile  decay.  The  expression  is  not  due  to  local 
oedema,  for  it  does  not  pit,  and  may  often  be  removed  in- 
stantly by  causing  the  expression  of  joyousness  or  laughter, 
when  the  orbicular  muscle  is  energised  and  temporarily 
recovers  its  tone. 

More  might  be  said  of  this  antithesis  of  the  muscular  state 
in  the  opposite  conditions  of  the  centres  of  feeling.  It  is  not 
suggested  that  the  appearance  of  the  face  accompanies  head- 
ache only,  it  is  common  in  many  conditions  of  depression. 


RECURRENT   HEADACHES  IN  CHILDREN.  311 

Something  might  also  be  added  of  the  partial  ptosis  and 
pigmentation  of  the  lower  eyelid  sometimes  seen. 

The  muscular  condition  of  the  hand  in  such  patients  seems 
to  me  equally  characteristic  with  that  of  the  face.  There  is  a 
nervous  condition  of  the  hand,  as  there  is  a  nervous  condition 
of  the  face,  and  each  can  be  described  in  anatomical  terms. 
As  the  child  stands  up,  holding  his  hands  out  before  him  on  a 
level  with  the  shoulders,  palms  downwards,  and  fingers  spread 
out,  there  may  often  be  seen  a  peculiar  and,  I  think,  character- 
istic condition  of  the  hand.  The  wrist  droops  slightly,  at  the 
same  time  the  phalanges  are  extended  backwards  upon  the 
metacarpus,  the  second  phalanges  being  slightly  flexed,  and 
the  ungual  phalanx  either  flexed  or  in  a  straight  line  with  the 
middle  phalanx.  The  thumb  is  usually  simply  extended 
backwards  and  somewhat  abducted  from  the  fingers.  I  think 
that  this  position  of  the  hand  may  be  taken  as  an  item  of 
evidence  that  the  child  is  of  a  neurotic  habit,  with  mobile 
nerve-centres ;  it  may  be  seen  in  girls  convalescent  from  chorea, 
and  in  others  who  are  weak  and  nervous.  This  "  nervous 
hand  "  is  sometimes  seen  more  marked  on  the  left  than  on  the 
right  side.  I  have  now  under  observation  a  lad  and  a  man, 
both  the  subjects  of  partial  hemiplegia  apparently  from  organic 
disease,  in  whom  this  "  nervous  hand  "  is  well  seen  on  the  weak 
side.  Twitchings  of  the  fingers  were  very  commonly  seen, 
the  movements  being  usually  of  independent  digits,  and  most 
commonly  either  lateral  or  flexor,  less  commonly  extensor ;  the 
lateral  movements  appeared  the  most  characteristic. 

Believing  that  "  the  nervous  hand  "  was  owing  to  the  con- 
dition of  its  muscLes,  and  that  the  condition  of  its  muscles  was 
owing  to  the  condition  of  certain  nerve-centres,  the  conclusion 
arrived  at  was  that  the  position  of  the  hand  must  indicate  the 
condition  of  those  nerve-centres. 

Considering  the  illustrations  that  Darwin  has  brought  for- 
ward to  prove  that  the  emotions  are  expressed  by  the  exercise 
of  certain  muscles,  and  that  in  opposite  emotional  conditions 
(i.e.  opposite  conditions  of  nerve-centres?)  the  antithesis  of 
the  emotional  condition  is  expressed  by  an  antithesis  of  the 
muscular  condition,  my  observations  were   directed   by   this 

principle  of  antithesis. 

A  hand  almost  the  antithesis  of  "  the  nervous  hand,"  and 


312 


RECURRENT   HEADACHES  IN   CHILDREN. 


expressive  of  force  and  energy,  is  often  seen  in  men  when 
speaking  earnestly.  Here  the  wrist  is  extended,  the  meta- 
carpo-phalangeal  joints  and  interdigital  joints  are  flexed,  the 
thumb  is  also  moderately  flexed. 

It  is  of  course  the  7th  cranial  nerve  which  connects  the 
facial  muscles  with  their  nerve-centres.  If  the  centres  of  the 
7th  nerve  are  disturbed  in  conditions  of  depression  it  is  reason- 
able to  inquire  if  the  muscles  supplied  by  other  cranial  motor 
nerves  show  any  signs  of  relaxation  or  disturbed  equilibrium. 

The  3rd,  4th,  and  6th  nerves  supply  the  eye  muscles.  Evi- 
dence of  disturbance  of  the  motor  division  of  the  5th  nerve  is 
seen  in  the  great  frequency  of  tooth-grindiDg.  In  a  large 
proportion  of  my  cases,  the  teeth  were  found  flattened  upon 
their  edges,  as  the  result  of  tooth-grinding.  This  condition 
may,  I  think,  be  taken  as  another  physical  sign  of  the  nervous 
condition.  We  know  that  the  sensory  branches  of  the  5th 
nerve  are  largely  distributed  to  the  meninges. 

The  tongue  is  supplied  by  the  9th  nerve,  and  this  when  pro- 
truded was  usually  very  unsteady,  but  not  distinctly  jerked  in 
and  out  as  in  chorea. 

There  appears  to  be  some  evidence  of  disturbance  of  the 
pneumogastric  nerve  in  the  varying  condition  of  the  appetite, 
which  is  often  voracious,  often  very  poor ;  vomiting  may  ac- 
company or  succeed  the  headaches.  Illusions  of  sight  with 
headaches,  such  as  sparks,  colours,  hemiopia,  &c,  are  in  my 
experience  much  more  rare  in  children  than  in  adults. 

I  found  that  very  commonly  the  urine  was  of  high  specific 
gravity,  reaching  up  to  1030  or  1035,  and  loaded  with  urea. 
Uro-hsematin  was  also  usually  abundant ;  in  both  these  facts 
these  children  correspond  with  those  suffering  from  chorea. 

Fifty-eight  cases  were  arranged  in  a  tabular  form,  as  follows, 
showing  the  relations  to  age  and  sex  : — 


Ages.        !  3-4 

4-5 

5-6 

6-7 

7-8 

8-9 

9-10 

10-11 

11-12 

12-13    13-15 

Males      25 
Females  33 

1 

0 

2 

2 

2 

3 

8 
1 

2 
2 

5 

2 
5 

2 
4 

4 
2 

1         0 
4    1     5 

Totals     58      1 

4 

5 

9 

4 

e 

7 

6 

6 

5        5 

RECURRENT    HEADACHES   IN   CHILDREN.,  313 

Heredity  produced  a  marked  predisposition  to  this  neurotic 
condition ;  in  the  58  cases  there  was  a  history  of  recurrent 
headaches  in  the  mother  in  24  cases,  in  the  father  in  eight 
cases,  while  in  three  cases  there  were  examples  of  insanity  in 
the  family.  In  looking  at  the  faces  and  heads  of  children 
suffering  from  headaches,  I  found  in  many  cases  signs  of 
rickets,  and  when  in  the  general  clinique  of  children  the 
patient  was  seen  to  be  rickety,  headaches  were  found  in  most 
instances  ;  it  seems  then  that  rickets  in  childhood  is  a  strongly 
predisposing  cause  of  recurrent  headaches. 


METHODS  OF  PREPARING,  DEMONSTRATING,  AND 
EXAMINING  CEREBRAL  STRUCTURE  IN  HEALTH 
AND  DISEASE. 

BY   BEVAN   LEWIS,   L.E.C.P.  LOND. 

Senior  Assistant  Medical  Officer,  West  Riding  Asylum. 

I. 

COARSE   EXAMINATION   OF   THE   BRAIN   AND   ITS   MEMBRANES. 

Important  and  necessary  as  are  the  minute  investigations 
made  by  microscopic  agency  into  the  normal  structure  of  the 
brain  or  its  pathological  deviations,  we  must  guard  ourselves 
from  the  very  serious  error  of  considering  this  method  as 
essentially  and  exclusively  necessary  in  these  studies.  The 
error  to  which  I  allude  is  a  common  one,  and  is  too  apparent 
to  need  much  comment  upon  my  part ;  for  all  who  are  engaged 
in  the  prosecution  of  cerebral  histology  must  have  recognised 
the  prevailing  tendency  to  disregard  the  naked-eye  appear- 
ances of  the  brain,  or  to  regard  them  as  of  very  secondary 
import  compared  with  a  minute  investigation  aided  by  the 
complex  armamentarium  of  the  microscopist.  If  any  of  my 
readers  are  possessed  of  this  notion  I  would  ask  them  at  the 
outset  to  rid  themselves  immediately  of  the  fallacious  idea 
which,  if  fostered,  must  prove  a  serious  obstruction  to  the 
acquirement  of  that  intimate  acquaintance  with  the  true  signi- 
ficance of  the  varied  appearances  presented  by  normal  and 
diseased  tissues.  The  skilled  obstetrician  recognises  as  an 
invaluable  acquirement  that  tactus  eruditus  which  a  constant 
and  intelligent  employment  of  a  special  sense  can  alone  confer ; 
and  no  less  should  the  histologist  endeavour  to  obtain  a  special 
visual  tact,  a  highly  refined  and  educated  visual  power  which 
can  alone  enable  him  to  recognise  by  the  unaided  eye  appear- 
ances which  pass  ^wholly  unnoticed  by  the  casual  observer.  I 
cannot  too  strongly  insist  upon  this  point,  for  he  who  would 
successfully  study  the  morbid  anatomy  of  the  brain  must,  as  in 


CEREBRAL   STRUCTURE   IN   HEALTH   AND  DISEASE.      315 

the  morbid  anatomy  of  other  tissues,  begin  seriously  to  educate" 
the  eye  to  the  coarse  appearances  presented  to  the  unaided 
vision.     The  employment  of  a  hand-lens  of  two  to  four  inches 
focal  length  will  prove  of  service  here,  the  naked-eye  appear- 
ance being  contrasted  with  the  magnified  field,  and  the  eye 
thus    educated  up  to   recognising   characters  which   without 
the   aid  of   the  lens  were   previously  indefinite  or  unrecog- 
nisable.     Nothing    beyond    repeated    and    energetic    efforts 
in  this  direction  will  enlarge  the  area  of  the  visual  field  and 
present  to  the  mind  the  manifold  appearances  which  constitute 
an  unbroken  whole,  and  which  are  absolutely  necessary  to  a 
refined  interpretation  of  the  picture  presented  to  the  mind's 
eye.     Repeatedly  have  I  had  occasion  to  observe  that   the 
student,  after  a  full  curriculum  of  hospital  training — a  training 
which  should  pre-eminently  involve  the  high  culture  of  the 
sense  of  sight,  hearing,  and  touch — fails  wholly  to  appreciate 
the  most  obvious  abnormalities  of  the  cerebro-spinal  tissues,  and 
this  because  he  has  neglected  to  tutor  the  eye  so  far  as  to  learn 
what  to  look  for,  and  how  to  look  for  it.     If  you  place  before 
him  the  brain  of  a  case  of  chronic  mania,  without  coarse  lesion, 
and  note  his  observations  upon  the  appearances  of  a  section 
across  the  hemisphere,  it  will  be  found  that  beyond  a  statement 
that  the  grey  matter  is  pale,  anaemic,  and  wasted ;  that  the 
white  matter  is  altered  in  consistence,  and  presents  numerous 
coarse  vessels,  his  untutored  eye  teaches  him  no  more ;  and 
should  he  be  examined  even  for  the  grounds  upon  which  these 
statements  are  made,  a  too  evident  vagueness  will  be  apparent 
— his  ideas  on  relative  depth  of  cortex  or  anaemic  states  of  the 
brain  and  consistence  of  its  tissue  are  gauged  by  no  mental 
standard,   and  are  remarkable   only  for  their   indefiniteness. 
The  practised  eye  of  the  histologist,  however,  sees  far  more ; 
the  relative  depth  of  cortex  in  various  regions ;  the  relation 
borne  by  this  depth  to  normal  standards ;  the  varied  depths  of 
the  several  laminae  of  the  cortex,  their  distinctness  of  outline, 
general  and  local  vascularity,  as  well  as  the  deviations  in  hue 
dependent   upon   fatty   or   upon    pigmentary   changes.     The 
cedematous,  degenerated  aspect  of  the  medullary  tracts,  the 
presence  of  minute  sclerosed  patches,  and  a   host  of  other 
morbid  appearances,  present  to  his  mind  a  picture  which  the 


316      METHODS  OF   PREPARING,   DEMONSTRATING,   ETC., 

unpractised  eye  wholly  fails  to  appreciate.  To  those  who  are 
liable  to  err  in  the  direction  pointed  out,  I  now  address  myself 
in  the  hope  of  rendering  their  studies  of  the  naked-eye  appear- 
ance of  healthy  and  diseased  brain  more  inviting  and  instruc- 
tive, by  means  of  a  few  simple  directions  as  to  what  appearances 
are  to  be  sought  and  how  they  are  to  be  looked  for. 

A  few  further  statements  on  the  object  and  scope  of  these 
articles  may  not  prove  amiss. 

I  address  myself  almost  exclusively  to  the  student  who,  up 
to  the  present  time,  has  devoted  but  little  of  his  attention  to 
cerebral  pathology  or  to  the  histology  of  the  central  nervous 
system  ;  and  more  especially  to  asylum  medical  officers,  whose 
opportunities  for  research  in  this  field  are  so  numerous,  yet  so 
sadly  neglected.  Recognising  personally  the  want  of  a  concise 
summary  of  methods  of  examination  of  the  nervous  centres,  I 
shall  endeavour  here  to  place  at  the  disposal  of  the  student  the 
more  important,  essential,  and  trustworthy  information  in  this 
department  which  I  find  scattered  promiscuously  throughout 
an  extensive  literature.  If  amongst  these  gleanings  my  remarks 
should  appear  to  the  advanced  student  burdened  by  too  much 
detail,  my  excuse  must  be  that  the  primary  object  is  to  over- 
come the  difficulties  presented  by  these  studies  to  the  novice, 
difficulties  which  every  expert  observer  has  at  the  beginning 
to  encounter. 

THE   DURA   MATER   AND   VENOUS   SINUSES. 

General  Anatomical  Considerations. — It  is  necessary  here 
that  the  student  should  recall  to  mind  certain  anatomical 
details  affecting  the  relationships  of  this  membranous  invest- 
ment of  the  brain  which  have  an  important  pathological  signi- 
ficance, and  in  the  first  place  note  that : 

a.  The  dura  mater  is  a  fibro- serous  membrane;  the  outer 
surface  being  fibrous  and  rough,  the  inner  being  smooth  and 
polished  by  a  layer  of  epithelial  cells  constituting  a  parietal 
arachnoid. 

b.  Cut  off  a  small  portion  and  float  it  in  water.  The  rough 
pilose  outer  surface  due  to  the  numerous  fibrous  connections 
and  vessels  which  unite   it  to  the  inner  table  of  the  skull 


CEREBRAL   STRUCTURE   IN   HEALTH  AND  DISEASE.      317 

becomes  hereby  very  apparent  in  contrast  to  the  smooth  inner 
surface. 

c.  Next,  note  that  the  dura  mater  is  composed  of  two  distinct 
layers,  which,  by  their  divergence,  occasion  the  formation  of 
the  d inherent  venous  sinuses  ;  whilst  the  inner  layer,  by  its 
duplications,  forms  the  various  intra-cranial  membranous 
partitions,  the  falx  cerebri  and  cerebelli,  as  well  as  the 
tentorium. 

d.  Lastly,  observe  the  close  anatomical  relationships  be- 
tween the  lateral  sinuses  and  the  mastoid  cells,  and  again 
between  the  superior  petrosal  sinuses  and  the  internal  ear. 
Caries  of  the  petrous  portion  of  the  temporal  bone  and 
of  its  mastoid  cells  is  so  frequent  an  affection,  that  the  con- 
tiguity to  them  of  these  venous  sinuses  is  most  important  as 
likely  to  occasion  not  only  localised  pachymeningitis  or  in- 
flammation of  the  opposed  dura  mater,  but  inflammation  and 
thrombosis  of  the  venous  sinuses,  leading  probably  to  metastatic 
deposits  in  the  lung. 

e.  The  position  of  the  venae  G-aleni,  which  receive  the  blood 
returning  from  the  choroid  plexuses  and  open  into  the  straight 
sinus,  is  such  that  tumours  or  abscesses  of  the  mid-lobe  of 
the  cerebellum  would  compress  them. 

Upon  removal  of  the  skull-cap  the  student  should  proceed 
to  investigate  the  condition  of  the  dura  mater  after  the  follow- 
ing systematic  manner : 

1st.  Note  the  general  aspect  of  the  membrane  covering  the 
hemispheres. 

2nd.  Examine  the  several  venous  sinuses. 

3rd.  Observe  the  condition  of  the  dura  mater  in  those 
regions  at  the  base  where  there  exists  a  special  pro- 
clivity to  disease. 

1st.  As  to  the  general  appearance  of  the  Dura  Mater  at  the 
vault. — A  glance  at  the  superficial  aspect  of  the  dura  mater 
may  reveal  the  presence  of  inflammatory  products  which  are 
frequent  here.  If  present  note  their  character,  whether  they 
are  simple,  inflammatory  exudates,  capable  of  undergoing 
organisation,  or  whether  they  are  the  results  of  suppurative 
inflammation.  In  the  former  case,  observe  how  softened  the 
membrane  is,  and  how  readily  separable  from  the  bone ;  in 


318      METHODS   OF   PREPARING,  DEMONSTRATING,  ETC., 

the  latter  case  the  presence  of  pus  will  almost  certainly  lead 
to  the  detection  of  a  carious  state  of  the  internal  table  and 
diploe  of  the  skull,  and  a  more  or  less  sloughy  aspect  of  the 
disintegrating  membrane.  The  organisable  blastema  may  be 
found  in  various  stages  of  development,  as  loose  areolar  or 
thick  tough  fibrous  tissue,  or  it  may  have  formed  bony  plates 
which  eventually  unite  with  the  cranial  bones.  Should  dense 
fibrous  bands  be  formed,  adhesions  betwixt  the  dura  mater  and 
bone  occur,  chiefly  along  the  course  of  the  sutures,  or  in  local- 
ised islets  over  the  frontal  or  parietal  bones,  or  so  extensively 
that  it  is  impossible  to  remove  the  skull-cap  without  at  the 
same  time  including  the  dura  mater,  as  their  forcible  separa- 
tion would  entail  injury  to  the  brain. 

If  there  be  the  above  given  indications  on  the  surface  of 
recent  or  of  old  inflammation,  note  (1)  the  density,  (2)  thick- 
ness, (3)  swollen  (4)  appearance,  and  (5)  colour  of  the  mem- 
brane at  these  parts.  Eecent  inflammations  involve  much 
swelling,  interstitial  infiltration,  softening  and  looseness  of 
texture,  and  a  very  red  colour ;  whilst  the  effects  of  an  old 
inflammation  are  seen  in  a  callous  fibroid  induration  and 
thickening,  often  with  bony  concretions  formed  in  the  inter- 
stices of  its  texture,  together  with  the  adhesion  to  the  inner 
table  of  the  skull  just  alluded  to. 

The  student  must  be  prepared  to  make  allowances  for  the 
general  increase  in  thickness  and  firmer  adhesion  of  the  dura 
mater,  which  pertains  to  advanced  age  independent  of  inflam- 
matory changes.  Superficial  inspection  will  also  enable  him  to 
detect  attenuation  of  this  membrane  such  as  results  from  the 
pressure  of  a  hypertrophied  brain,  from  the  effusion  of  hydro- 
cephalus or  morbid  growths  Local  thinness  of  this  membrane 
also  will  be  frequently  found  due  to  the  pressure  of  pacchionian 
bodies  which  perforate  the  dura  mater  frequently,  and  imbed 
themselves  in  fossae  on  the  internal  surface  of  the  cranium. 

Extravasation  of  blood  forcing  the  membrane  apart  from 
the  bone  may  be  frequently  found,  and  its  origin  should  be 
carefully  sought. 

2nd.  Examine  the  larger  Venous  Sinuses. — A  fold  of  dura 
mater  close  to  the  longitudinal  sinus  at  its  exposed  frontal 
extremity   must    now   be   pinched  up   by    forceps,   and   the 


CEREBRAL   STRUCTURE   IN  HEALTH   AND   DISEASE.      319 

scalpel  passed  through  it  and  down  into  the  longitudinal 
fissure  of  the  brain,  so  as  to  divide  the  union  betwixt  the 
falx  cerebri  and  crista  galli.  Introduce  a  curved  bistoury  into 
the  anterior  end  of  the  longitudinal  sinus,  and  carry  the  blade 
backwards  to  its  occipital  extremity  so  as  to  expose  this  sinus 
throughout  its  greater  extent.  The  oblique  orifices  of  the 
veins  of  the  vertex  which  empty  themselves  into  this  sinus 
will  now  be  exposed.     Note — 

(1.)  The  capacity  of  the  sinus  throughout. 

(2.)  The  nature  of  its  contents. 

(3.)  The  condition  of  its  lining  membrane. 

The  incision  through  the  frontal  end  of  the  falx  cerebri 
should  now  be  extended  on  either  side  through  the  dura  mater 
backwards,  upon  a  level  with  the  sawn  edge  of  the  cranial 
bones.  The  anterior  extremity  of  the  falx  being  then  seized 
with  forceps  should  be  drawn  forcibly  backwards  from  between 
the  hemispheres,  carefully  dividing  the  great  superficial  veins 
where  they  open  into  the  sinus,  when  the  convolutionary  aspect 
of  the  brain  covered  by  its  soft  membranes  will  be  exposed  to 
view.  At  this  stage  of  dissection  the  pia  mater,  arachnoid,  and 
superficial  aspect  of  the  brain  will  require  attention,  and  the 
method  to  be  adopted  will  be  detailed  in  the  following  section, 
to  which  the  student  must  be  referred.  Continuing,  however, 
our  examination  of  the  sinuses  of  the  dura  mater,  it  must  be 
presumed  that  the  brain  has  been  removed,  and  the  following 
procedure  will  then  be  necessary : 

Lay  open  the  larger  venous  sinuses  at  the  base,  commencing 
at  the  torcular  Herophili  behind,  and  carrying  the  blade  down 
each  lateral  sinus  to  the  foramen  jugulare.  Open  up  the 
straight  sinus  running  into  the  torcular  Herophili  in  the  base 
of  the  falx  cerebri.  Deal  in  like  manner  with  the  petrosal  and 
cavernous  sinuses. 

A  close  inspection  of  these  sinuses  should  be  instituted  with 
the  object  of  learning  the  nature  of  their  contents,  and  the 
morbid  or  healthy  condition  of  the  textures  of  these  venous 
channels.  The  most  frequent  morbid  conditions  found  here 
are  those  of  phlebitis  and  thrombosis,  the  thrombus  being 
usually  the  result  of  inflammation  of  the  walls  of  the  sinus. 

Thrombosis  of  the  venous  sinuses  of  the  dura  mater  is  so 


320        METHODS   OF   PREPARING,   DEMONSTRATING,   ETC., 

frequent  and  so  important  an  affection,  that  the  possibility  of 
its  occurrence  should  always  suggest  itself  when  examining 
this  membrane. 

If  a  thrombus  obstructs  any  one  of  these  sinuses,  note  the 
more  or  less  organised  condition  of  the  clot  and  its  adhesion 
to  the  lining  membrane  of  the  sinus. 

Examine  closely  its  apparent  site  of  origin  and  extensions, 
the  latter  often  reaching  into  the  jugular  veins. 

Next  take  into  consideration  the  constitution  of  the  clot, 
whether  recent,  organised  and  firm,  or  breaking  up  and  present- 
ing the  appearance  of  a  crumbling  mass,  which,  during  life, 
would  give  rise  to  metastatic  deposits  in  distant  organs. 

The  condition  of  the  lining  membrane  and  tissues  of  the 
sinus  should  next  be  noted.  If  inflamed,  the  inflammatory 
action  should  be  traced  to  its  origin,  usually  in  a  carious  state, 
of  the  cranial  bones  ;  or  by  extension  of  simple  inflammation 
of  the  dura  mater  in  the  neighbourhood  of  the  sinus ;  or  less 
frequently,  induced  as  a  secondary  result  of  thrombosis.  The 
student  should  carefully  study  the  effect  of  plugging  of  the 
different  sinuses,  and  their  proclivity  to  disease  as  a  result  of 
their  varied  anatomical  relationships. 

'a.  Inflammation  of  the  longitudinal  sinus  will  be  accom- 
panied by  occlusion  of  the  venous  trunks  from  the  convexity 
of  the  brain  where  they  open  into  the  sinus. 

b.  If  the  straight  sinus  be  occluded  as  the  result  of  adhesive 
phlebitis,  the  student  will  remark  that  its  effects  in  obstructing 
the  return  of  blood  from  the  choroid  plexus  will  be  similar  to 
what  occurs  when  the  venae  Galeni  are  compressed  by  a  tumour 
of  the  mid-lobe  of  the  cerebellum.  Effusion  into  the  ventricles 
might  be  expected  in  these  cases,  and  the  enlargement  of  the 
head  from  this  cause  has  been  recognised  clinically. 

c.  If  the  lateral  sinus  be  inflamed,  we  might  expect  as  a 
result  extension  of  phlebitis  into  the  jugular  veins,  and  plug- 
ging of  the  smaller  sinuses  or  veins  opening  into  it.  In  con- 
nection with  this — note,  that  the  small  "emissary  veins," 
(Santorini)  which  perforate  the  bone  at  the  anterior  extremity 
of  the  lateral  sinus.,  and  which  form  a  communication  between 
the  sinus  and  the  veins  on  the  outside  of  the  skull  at  the  back 
of  the  head,  may  become  plugged  by  a  thrombus  producing  a 


CEREBRAL   STRUCTURE   IN   HEALTH   AND   DISEASE.       321 

painful  oedema  behind  the   ear,  also  recognised  clinically  by 
Griesinger.1 

d.  The  position  of  the  petrosal  and  lateral  sinuses  naturally 
exposes  them  to  phlebitis  and  thrombosis.  Lying  on  the 
petrous  portion  of  the  temporal  bone,  they  are  always  liable  to 
be  implicated  by  extension  of  inflammation  from  the  internal 
ear  and  caries  of  the  temporal  bone. 

e.  Thrombosis  of  the  cavernous  sinus  has  been  frequently 
noted.  In  connection  with  this  condition  the  student  must  be 
prepared  to  note  the  pressure  which  will  probably  result  to  the 
carotid  artery  which  runs  through  this  sinus  invested  by  its 
lining  membrane.2  He  may  also  look  for  extension  of  in- 
flammation of  the  coats  of  this  sinus  to  the  facial  veins  with 
which  the  ophthalmic  vein  communicates,  as  well  as  to  obstruc- 
tion to  the  return  of  blood  from  the  cavity  of  the  orbit. 

/.  Amongst  other  results  of  thrombosis  of  the  cerebral  veins 
and  sinuses,  will  often  be  found  punctiform  haemorrhages  into 
the  substances  of  the  brain. 

3rd.  Observe  the  condition  of  the  dura  mater  at  the  base 
where  there  exists  a  special  proclivity  to  disease.  The  sites 
alluded  to  are : 

1.  Petrous  portion  of  temporal  bone. 

2.  Ethmoidal  plate. 

3.  Parts  adjoining  superior  cervical  vertebrae. 

THE  ARACHNOID  AND  PIA  MATER. 

General  Anatomical  Considerations. — In  proceeding  to  in- 
vestigate the  healthy  and  morbid  appearances  of  the  arachnoid 
the  following  anatomical  facts  will  prove  serviceable  to  the 
student. 

1.  The  arachnoid  is  usually  regarded  as  consisting  of  a 
parietal  and  visceral  layer  like  ordinary  serous  sacs,  the 
former  however  (parietal  layer)  being  merely  a  layer  of  nucleated 
polygonal  epithelium  lining  the  inner  surface  of  the  dura 
mater ;  the  latter  forming  the  far  more  substantial  investment 

1  Quoted  by  Niemeyer  in  '  Text- Book  of  Practical  Medicine,'  vol.  ii. 

2  This  condition  has  been  recognised  clinically  by  a  loud  bruit  heard  on  auscul- 
tation of  the  skull.    Dowse.     '  Lancet.' 

VOL.   III.  Y 


322      METHODS   OF   PREPARING,   DEMONSTRATING,   ETC., 

of  the  convolutions  of  the  brain  separated  from  them  by  the 
pia  mater.  This  closed  sac  is  lubricated  by  a  portion  of  the 
general  cerebro-spinal  fluid. 

2.  The  visceral  layer  of  arachnoid  does  not  dip  into  the 
sulci  with  the  pia  mater,  but  bridges  them  across,  whilst  in 
other  regions  it  is  widely  separated  from  the  pia  mater  so  as 
to  enclose  between  them  extensive  spaces.  Thus  at  the  base  a 
delicate  veil  of  arachnoid  stretches  across  the  pons  and  inter- 
peduncular space  as  far  as  the  optic  chiasma ;  a  similar  film  of 
arachnoid  closes  in  the  fourth  ventricle  stretching  across  from 
the  medulla  to  the  cerebellum;  the  arachnoid  also  does  not 
pass  down  to  the  bottom  of  the  longitudinal  fissure,  but  spans 
across  immediately  beneath  the  falx  cerebri ;  hence  a  space  is 
left  here  between  the  two  inner  membranes  of  the  brain 
immediately  above  the  corpus  callosum. 

3.  The  various  spaces  alluded  to  above  all  communicate 
freely  with  one  another,  and  with  an  extensive  space  around 
the  whole  length  of  the  spinal  cord  betwixt  the  pia  mater  and 
arachnoid  sac.  The  whole  system  of  spaces  is  termed  the 
sub-arachnoid  space,  and  is  .filled  by  the  greater  bulk  of 
the  cerebro-spinal  fluid. 

4.  A  space  intervenes  between  the  parietal  layer  of  the 
arachnoid  and  the  dura  mater.  It  has  been  fully  investigated 
and  described  by  Axel  Key  and  Eetzius,1  and  is  called  by 
these  anatomists  the  sub-dura-mater  space  (subduralraum). 
The  student  must  therefore  regard  the  membranous  invest- 
ments of  the  brain  as  consisting  of  a  firm  and  immovable 
fibrous  outer  membrane,  the  dura  mater  forming  also  the 
periosteal  lining  of  the  cranial  cavity;  of  an  intermediate 
serous  sac  or  arachnoid  whose  visceral  layer  moves  freely  with 
the  movements  of  the  hemisphere ;  and  lastly,  of  a  vascular 
membrane  supporting  the  blood-supply  of  the  brain — the  pia 
mater,  which  closely  lines  the  cortex  dipping  into  the  sulci 
and  being  prolonged  into  the  ventricles. 

Between  the  various  investments  are  four  great  cavities : 
1.  The  subdura-matral  betwixt  dura  mater  and  the  parietal 
arachnoid. 

1  '  Studien  in  der  Anatomic  des  Nervensystems.'  Axel  Key  und  Gustav  Retzius. 
Stockholm,  1875. 


CEREBRAL   STRUCTURE   IN   HEALTH   AND   DISEASE.     323 

2.  The  arachnoid  cavity  formed  by  the  arachnoid  sac. 

3.  The  sub-arachnoid  cavity  betwixt  visceral  arachnoid  and 
pia  mater. 

4.  The  epi-cerebral  space  betwixt  pia  mater  and  cortex. 

It  must  also  be  borne  in  mind  that  compensatory  adjust- 
ments for  lessened  or  decreased  intra-cranial  pressure  are 
obtained  by  means  of  the  cerebro-spinal  fluid  ;  increase  in  the 
pressure,  as  in  the  increased  amount  of  blood,  growth  of  tumours, 
&o,  being  allowed  for  by  escape  of  this  fluid  into  the  spinal  sub- 
arachnoid space.  In  relation  to  this  important  subject  it  has 
been  shown  by  Axel  Key  and  Eetzius  that  the  pressure  of  the 
cerebro-spinal  fluid  is  always  higher  than  that  of  the  venous 
blood  and  its  specific  gravity  lower,  hence  its  free  mingling 
with  the  blood-currents  by  osmosis  is  much  facilitated.1 

Coarse  Methods  of  Examination. — The  healthy  and  morbid 
appearance  of  the  arachnoid  should  be  subjected  to  close  and 
critical  examination. 

Upon  reflecting  the  dura  mater  the  contents  of  the  arachnoid 
sac  will  be  revealed,  and  in  relation  to  this  point  we  must 
note  : 

1.  Variations  in  the  amount  of  cerebro-spinal  fluid  here. 

2.  Modified  appearance  of  this  fluid  from  admixture  with 
morbid  products. 

3.  Note  expecially  extravasations  of  blood,  and  the  age  of 
these  haemorrhages  as  revealed  by  the  condition  of  the  clot.  It 
may  be  purely  fluid  blood,  coagula,  or  a  delicate  film  of  fibrinous 
nature  ;  or  it  may  be  in  various  stages  of  organisation.  The 
various  stages  of  the  arachnoid  cyst  in  relation  to  pachy- 
meningitis have  all  been  most  graphically  described. 

4.  Note  the  superficial  aspect  of  the  visceral  and  parietal 
arachnoid  as  regards — 

a.  Absence  of  clear,  moist,  glistening  surface. 

b.  Presence  of  morbid  deposits,  such  as  films  of  lymph  of 

varied  appearance  and  stage  of  organisation ;  as  a 
delicate  greyish  mucus-like  exudation,  or  a  mem- 
brane possessing  a  certain  amount  of  consistence, 
or  flakes  which  are  yellow  and  puriform,  and  more 

1  •  Studicn  in  der  Anatomie  des  Nervensystems.'  Axel  Key  und  Gustav  Retzius. 
1875. 

Y   2 


324        METHODS  OF  PREPARING,   DEMONSTRATING,   ETC., 

rarely  fibroid  patches ;   or,  again,  the  development 
of  bony  plates  in  the  parietal  layer. 
c.  Adhesions  between   layers   of  arachnoid  sac,  such  as 
occur  naturally  by  the  development   of  the  pac- 
chionian bodies. 

5.  Note  the  anomalies  of  texture  due  to  interstitial  change 
and  to  deposits  occurring  here.  The  effect  of  frequent  hyper- 
emia is  seen  in  the  opalescent,  creamy  white  or  perfectly 
opaque  appearance  presented,  especially  along  the  course  of 
the  blood-vessels,  and  always  seen  after  middle  life  to  a  greater 
or  less  extent.  Hypertrophy  of  the  textures,  giving  the  mem- 
brane a  tough  and  thick  character,  will  result  from  similar 
causes.  The  membranes  may  be  however  soft,  tumid,  and 
swollen  from  oedema  of  its  texture ;  and  where  it  bridges  the 
sulci  a  solid  gelatiniform  aspect  is  often  given  it  by  the  fluid 
subjacent. 

6.  The  relative  amount  of  cerebro-spinal  fluid  in  the  sub- 
arachnoid space  should  next  be  taken  into  account.  It  should 
be  collected,  together  with  that  which  escapes  from  the  arach- 
noid sac  and  ventricles,  and  carefully  measured.  The  appear- 
ance of  the  arachnoid,  when  buoyed  up  by  any  undue  amount 
of  this  fluid,  should  be  noted  before  removal  of  the  brain  from 
the  skull.  It  will  be  found  that  in  these  cases  the  arachnoid 
is  widely  separated  from  the  pia  mater  by  the  subjacent  fluid. 
The  limpid  character  of  this  fluid  may  be  tested  by  slitting  up 
the  arachnoid  over  a  sulcus. 

So  far  our  remarks  chiefly  apply  to  the  arachnoid,  and  we 
will  now  turn  our  attention  to  the  pia  mater.  The  proximity 
of  these  two  membranes  to  one  another  of  course  predisposes 
to  their  common  implication  in  any  morbid  process,  yet 
the  pia  mater  is  occasionally  involved  without  extension  to  the 
brain  substance,  and  still  more  frequently  without  extension 
to  the  arachnoid.  In  healthy  states  these  membranes  are 
very  thin  and  delicate,  and  removed  from  the  brain  surface 
only  with  difficulty.  We  should  therefore  note  their  proximity 
to  each  other  over  the  summits  of  the  gyri,  alterations  in  the 
thickness  of  the  pia  mater  and  in  its  toughness,  infiltrations  of 
its  texture,  and  the  ease  or  difficulty  experienced  in  its  removal 
from  the  cortex. 


CEREBRAL  STRUCTURE  IN  HEALTH  AND  DISEASE.      325 

Thus  the  pia  mater  may  be  found  widely  separated  from  the 
arachnoid,  the  latter  being  buoyed  up  by  sub-arachnoid  effusion. 
In  these  cases  the  appearance  of  the  fluid  should  be  noted, 
especially  as  regards  the  presence  of  inflammatory  exudates, 
as  flakes  of  lymph,  &c. 

If  thickened  in  texture  the  alteration  of  the  pia  mater  should 
be  traced  to  its  origin,  whether  this  be  simple  serous  infiltra- 
tion or  oedema  conjoined  with  inflammatory  material.  Tortuosity 
and  varicosity  of  the  vessels  will  also  be  further  indications  of 
repeated  congestions  of  this  membrane.  Especial  caution  must 
be  observed  against  drawing  hasty  conclusions  regarding  con- 
gestion of  the  membranes  from  the  mere  fulness  of  their 
blood-vessels  and  hypostasis.1 

The  student  will  find  ample  opportunity  for  studying  the 
appearances  presented  by  oedema  and  thickening  of  the  soft 
membranes  of  the  brain  in  cases  of  senile  atrophy,  general 
paralysis,  and  alcoholism. 

The  presence  of  inflammatory  material  modifying  the  thick- 
ness and  toughness  of  the  membranes  should  lead  to  a  study  of 
the  nature  of  the  exudate,  whether  it  appears  as  a  tough  exudate 
of  plastic  lymph  more  or  less  yellowish  in  hue,  or  more  serous, 
sero-purulent,  opaque,  and  less  organisable  material. 

With  the  presence  of  these  more  or  less  plastic  exudates  note 
the  general  infiltration  of  the  membranes  around  with  greyish, 
opaque  serum.  Such  changes  afford  excellent  opportunities 
for  the  study  of  the  results  of  inflammatory  action  in  loose 
areolar  tissue.  In  connection  with  inflammation  of  the  pia 
mater,  a  condition  which  will  frequently  engage  the  attention 
of  the  student,  he  should  also  follow  up  his  investigation  of  the 
nature  of  the  exudate  by  examining  also : 

a.  The  direction  taken  by  the  morbid  product,  noting  that 

this  occurs  almost  invariably  along  the  vascular 
tracts,  the  course  of  the  vessels  being  marked  out 
by  opacities. 

b.  The  extension  to  neighbouring  structures  (brain,  arach- 

noid, dura  mater,  and  skull). 
o.  The  restriction  of  inflammation  to  limited  areas  (as  when 

1  On  this  point  see  Niemeyer.    Art.  Hyperemia  of  Brain  and  its  Membranes. 
'  Text-Book  of  Medicine,'  vol.  ii. 


326      METHODS  OP   PREPARING,   DEMONSTRATING,  ETC., 

originating  secondarily  from  caries  of  the  cranial 
bones) ;    or  to  the   convexity  of  the   hemispheres 
(chiefly    accompanied   by   plastic    products) ;    or, 
lastly,  characterised  by  the  base  of  the  brain  being 
originally  and  chiefly  involved   (usually   accom- 
panied by  aplastic  and  tubercular  products). 
Note  attentively  the  greater  or  less  facility  of  stripping  the 
pia  mater  from  the  cortex.    The  membrane  may  be  cedematous, 
thickened,  gelatinous,  and  most  readily  removed ;  or,  on  the 
other  hand,  it  may  cling  with  greater  tenacity  or  adhere  so 
firmly  that  portions  of  the  cortex  tear  away  with  it,  leaving  an 
eroded,  worm-eaten  aspect  of  the  surface  of  the  gyri.    Attention 
should  be  directed  to  the  strength  of  these  adhesions,  their 
implication  of  the  summits  of  the  gyri  only,  their  localisation 
over  the  convolutionary  surface  of  the  brain,  and  the  coarse- 
ness of  the  blood-vessels  entering  the  cortex-  at  the  sites  of 
adhesion.     Whenever  the  student  is  engaged  with  a  case  of 
meningitis,  the  morbid  topography  must  be  carefully  studied. 
If  basic,  the  veil  of  arachnoid  extending  from  the  optic  chiasm 
to  the  pons  must  be  examined  and  removed,  noting  implication 
of  the  numerous  vascular  and  fibrous  twigs  extending  betwixt 
it  and  the  subjacent  pia  :  follow  these  results  of  inflammatory 
action  up  along  the  vessels  of  the  fissure  of  Sylvius  and  along 
the  anterior  cerebrals  in  the  longitudinal  fissure.   Examine  the 
regions  just  named  for  tubercular  granulations,  paying  especial 
attention  to  the  smaller  blood-vessels  which  may  have  tuber- 
cular masses  in  their  sheaths,  occluding  more  or  less  the  calibre 
of  the  vessel.     Should  granulations  appear  around  the  blood- 
vessels, let  them  be  removed  and  floated  in  water  for  more 
careful  observation. 


ARTERIAL   SYSTEM   OF   THE   BRAIN. 

After  carefully  noting  the  external  appearance  of  the  mem- 
branes covering  the  hemispheres  both  at  the  vertex  and  the 
base,  the  condition  of  the  arterial  system  should  be  inquired 
into.  The  brain  being  placed  with  its  base  uppermost,  the  fine 
expanse  of  arachnoid  which  bridges  across  the  inter-peduncular 
space  is  first  removed,  and  the  great  vessels  forming  the  circle 


CEREBRAL   STRUCTURE   IN  HEALTH  AND  DISEASE.     327 

of  Willis  will  then  be  exposed  to  view.  Now  separate  the 
temporo-sphenoidal  lobe  from  the  adjacent  frontal  and  parietal 
lobes  by  dividing  the  bridge  of  arachnoid  extending  between 
them  across  the  Sylvian  fissure.  On  gently  drawing  back  the 
temporo-sphenoidal  lobe  the  Sylvian  branch  of  the  middle 
cerebral  artery  will  be  observed  running  deeply  in  the  fissure 
towards  the  upper  extremity  of  the  latter,  giving  off  small 
branches  in  this  course.  The  radiating  gyri  of  the  island  of 
Reil  (central  lobe)  will  in  most  cases  be  only  partially  exposed, 
and  it  will  be  necessary  to  separate  the  operculum,  or  that  por- 
tion of  the  third  or  inferior  frontal  convolution  which  laps  over 
the  anterior  portion  of  this  lobe.  The  five  or  seven  gyri  of  the 
island  will  now  be  seen  radiating  outwards  like  a  fan  and  sup- 
porting the  various  branches  derived  from  the  middle  cerebral 
artery  in  the  sulci  between  them.  Split  up  the  arachnoid  which 
bridges  across  the  longitudinal  fissure  anteriorly  from  one 
frontal  lobe  to  the  other.  We  shall  thus  have  exposed  the 
various  branches  of  the  circle  of  Willis  as  far  as  they  can  be  seen 
at  the  base.     Note  first  the  arrangement  of  the  blood-vessels. 

A  first  glance  at  the  arrangement  of  the  great  arteries  at  the 
base  of  the  brain  entering  into  the  formation  of  the  circle  of 
Willis  cannot  fail  to  impress  upon  the  student's  mind  this  im- 
portant fact :  there  are  here  two  great  arterial  systems  more  or 
less  distinct  and  independent.  In  front  lies  the  carotid  system, 
supplying  by  far  the  greater  bulk  of  the  brain ;  behind  lies  the 
vertebral  system,  distributed  to  the  posterior  and  inferior  regions 
of  the  cerebrum — an  area  small  in  comparison  to  the  former. 
These  two  great  arterial  systems  are  united  by  the  two  posterior 
communicating  arteries  which  connect  each  carotid  with  its 
corresponding  posterior  cerebral  artery.  Examine  the  pos- 
terior communicating  arteries  and  note  the  remarkable  small- 
ness  of  their  calibre,  a  fact  which  suffices  to  ensure  us  that  the 
circulation  in  the  carotid  and  vertebral  systems  is  in  the  main 
distinct;  whilst  the  arrangement  allows  of  compensatory  en- 
largement and  a  free  communication  betwixt  both  systems 
where  emboli,  thrombi,  or  diseased  textures  obstruct  the  circu- 
lation of  a  main  branch. 

Next  observe  the  junction  between  the  two  "anterior  cerebral 
arteries  deep  in  the  longitudinal  fissure  by  means  of  the  cross 


328      METHODS   OF  PREPARING,  DEMONSTRATING,  ETC., 

branch,  the  anterior  commnnicating  artery.  Baise  the  branch 
on  the  forceps  and  note  its  short  length,  small  calibre,  and  right- 
angled  direction — facts  which  teach  the  student  that,  although 
in  case  of  obstruction  on  the  carotid  side  of  the  anterior  cerebral 
artery,  this  branch  by  dilating  may  afford  a  satisfactory  re- 
establishment  of  circulation  over  the  area  to  which  it  is  distri- 
buted, yet  for  the  greater  part  the  circulation  betwixt  the  two 
anterior  cerebral  arteries  is  distinct. 

A  little  further  consideration  will  teach  him  that  the  circu- 
lation of  each  hemisphere  is  by  the  above  mechanism  rendered 
wholly  distinct  and  independent ;  that  the  circulation  of  the 
mid-cerebral  region  of  one  side  is  wholly  separated  from  that 
of  the  opposite  hemisphere ;  whilst  the  anterior  cerebral  areas 
are  more  closely  associated  through  the  medium  of  an  anterior 
communicating  branch. 

Lastly,  through  the  medium  of  the  posterior  communicating 
artery  (especially  when  we  recall  to  mind  the  frequent  enlarge- 
ment of  this  vessel  met  with)  there  will  be  a  far  more  ready 
communication  betwixt  the  carotid  and  vertebral  circulation 
than  there  can  be  betwixt  the  vascular  apparatus  of  both 
hemispheres.  The  student  should  pay  especial  attention, 
therefore,  to  the  following  observations  : 

a.  The   almost  complete    independence   of   hemispheric 

circulation. 

b.  The  very  complete  independence  established  betwixt 

the  circulation  of  one  middle  cerebral  and  that  of 
the  other. 
e.  The  interdependence  possible  betwixt  the  two  anterior 
cerebral     streams    through    the    medium    of    an 
enlarged  communicating  branch. 
d.  The  possible  admixture  of  the  carotid  and  vertebral 
circulation  of  the  same  side  through  the  medium 
of  the  posterior  communicating — a  condition  very 
frequently  established. 
The  arrangement  of  the  internal  carotid  ere  it  reaches  the 
circle  of  Willis  is  one  of  interest  and  significance.     Within 
its  bony  canal  the  tortuous  sigmoid  course  taken  by  it  is  un- 
doubtedly one  means  whereby  the  brain  is  protected  from  the 
results  of  the  cardiac  pulsations.     The  student  will  recall  a 


CEREBRAL  STRUCTURE   IN  HEALTH  AND  DISEASE.      329 

similar  tortuous  course  taken  by  the  vertebral  artery  ere  it 
enters  the  cranium.  It  has  long  been  noticed  that  the  middle 
cerebral  is  more  readily  blocked  by  emboli  than  the  other 
branches,  and  that  the  area  of  its  distribution  shows  especial 
proclivity  to  haemorrhage.  Anatomical  reasons,  and  the  fact 
that  this  vessel  lies  "  more  directly  in  the  way  of  strain  from 
the  heart  explains  its  frequent  plugging  and  rupture  from 
disease."  (Hughlings-Jackson.1)  Thus  Prevost  and  Cotard 
found  that  tobacco-seeds  injected  into  a  dog's  carotid  most  often 
lodged  in  the  middle  cerebral  artery.  Again,  the  fact  that  the 
left  carotid  artery  arises  directly  from  the  summit  of  the  aortic 
arch  whilst  the  right  arising  from  the  innominate  is  inclined  at 
an  angle  to  the  aortic  current,  is  sufficient  to  explain  the  greater 
immunity  from  embolism  experienced  by  the  right  carotid 
in  its  distribution  to  the  brain.  The  right  vertebral  arises 
from  the  horizontal  part  of  the  subclavian,  and  is  therefore  also 
less  subject  to  embolism  than  the  left  vertebral  which  arises 
from  the  summit  of  the  ascending  portion  of  the  left  subclavian. 
(Duret.) 

SUPERFICIAL   VIEW   OF  ARTERIES   AT   THE   BASE. 

Note  the  following  points : 

a.  Colour  and  opacity. 

b.  Eelative  toughness  of  coats. 

e.  Tortuosity  or  kinks  in  the  course  of  the  vessel. 

d.  Local  bulgings  or  constrictions  from  diseases  of  texture. 

a.  The  arteries  may  be  perfectly  white  in  cases  of  slow  and 
lingering  death,  and  contain  a  decolorised  clot  extending  into 
their  minute  ramifications.  On  the  other  hand,  they  may  be  of 
a  deep  red  hue  from  fluid  blood,  dark  clots,  and  blood  stain- 
ing of  the  lining  membrane.  The  vessels  again  may  be  thin 
and  semi-transparent,  or  opaque  from  thickening  of  the  arterial 
tunics  and  morbid  deposits. 

6.  The  toughness  of  the  arterial  tunics  can  be  tested  later 
on  after  their  removal.  Their  resistance  to  strain  is  an 
important  feature,  and  due  attention  should  be  paid  to  it  by 
the  student.     The  apparent  thinness  of  a  vessel  should  never 

1  '  Lancet,'  Sept.  4,  1875. 


330      METHODS  OF  PREPARING,  DEMONSTRATING,  ETC, 

be  allowed  to  deceive  him,  as  the  thicker  vessels  are  often 
most  degenerated  and  least  resistant  to  traction  or  expansion. 
Traction  may  be  applied  to  the  vessel  held  between  two  pairs 
of  forceps,  when  an  approximate  idea  of  the  breaking  strain 
may  be  acquired,  whilst  the  use  of  the  conical  gauge  will 
enable  him  to  note  the  various  degrees  of  resistance  these 
textures  offer  to  expanding  forces. 

e.  Tortuosity  and  kinks  in  the  smaller  branches  should  be 
noted  as  suggestive  of  previous  forcible  distension  from  con- 
gestion. This  is  apparent  often  in  the  larger  arteries ;  thus 
Quain  has  noticed  frequent  tortuosity  of  the  internal  carotid 
before  it  enters  the  carotid  canal  outside  the  skull  in  apoplectic 
subjects. 

d.  Local  bulgings  may  be  due  to  aneurismal  dilatations,  to 
the  different  forms  of  arteritis — atheroma,  tubercle,  syphilitic 
gummata,  or  to  the  impaction  of  a  thrombus  or  embolus.  The 
arteries  at  the  base  will  be  found  often  exceedingly  athero- 
matous, tortuous,  knotty,  and  white ;  the  amount  of  athero- 
matous material  occluding  even  the  larger  cerebral  arteries, 
often  converting  the  smaller  branches  into  irregular  knotty 
cords.  The  student  should  never  infer  from  the  aspect  or  feel 
of  such  a  vessel  that  it  is  occluded,  but  he  should  always  make 
a  section  across  the  mass  of  diseased  tissue,  when  if  the  vessel 
be  permeable  the  orifice  is  readily  detected.  Note  particularly 
the  branches  which  are  occluded.  If  the  bulging  be  due  to 
inflammatory  swelling  and  exudation  into  the  outer  tunics  of 
the  artery,  it  will  be  observed  that  corresponding  to  the  site  of 
lesion  the  vessel  is  dilated — a  condition  due  to  paralysis  of 
the  muscular  coat  of  the  vessel,  together  with  implication  of 
the  elastic  outer  tunic.  Make  a  section  across  the  inflamed 
tissue,  and  observe  how  readily  the  elastic  or  outer  coat  may 
be  stripped  from  the  muscular  by  means  of  forceps ;  also  how 
friable  and  easily  separable  are  the  muscular  fibres  of  the 
media.  The  inner  coat  will  also  be  probably  deeply  stained 
by  haematin,  or  may  be  eroded  and  covered  by  an  adherent 
clot  immediately  beneath  the  inflamed  patch.  When  a  clot 
appears  to  obstruct  the  calibre  of  a  blood-vessel,  the  character 
of  the  clot  should  be  taken  into  consideration,  its  fibrinous 
constitution,  stage  of  organisation,  adhesion  to  vascular  walls 


CEREBRAL   STRUCTURE   IN   HEALTH   AND  DISEASE.      331 

its  form,  prolongations,  and  appearance  of  its  section.  The 
sheath  and  outer  tunic  of  the  arteries  should  be  closely  exa- 
mined, especially  in  the  neighbourhood  of  the  Sylvian  iissure 
and  island  of  Eeil  for  tubercular  or  syphilitic  growths.  Espe- 
cial care  must  be  taken  to  exactly  note  the  arterial  tunics 
involved,  so  as  to  discriminate  between  ordinary  endarteritis 
resulting  in  atheromatous  degeneration  and  the  syphilitic  node 
or  gumma  involving  the  outer  coats,  and  the  tubercular  nodules 
involving  the  arterial  sheaths,  all  of  which  lesions  may  give 
rise  to  blocking,  contraction  of  the  cavity,  and  thrombosis. 
Such  lesions  should  be  examined  microscopically.  In  all  cases 
the  above  superficial  examination  should  be  supplemented  by 
removal  of  short  lengths  of  any  diseased  vessels,  to  be  reserved 
for  freezing  and  section-cutting,  according  to  the  methods 
detailed  hereafter  in  the  microscopic  section. 

The  vessels  spreading  over  the  island  of  Keil  and  up  the 
Sylvian  fissure  should  now  be  raised  by  passing  a  pair  of  forceps 
beneath  them,  and  with  a  clean  sweep  of  the  scalpel  they 
should  be  all  divided  just  where  they  turn  over  on  to  the 
superficial  aspect  of  the  brain  ;  this  should  be  repeated  on  the 
opposite  side.  The  two  anterior  cerebral  arteries  should  now 
be  divided  at  the  genu  of  the  corpus  callosum,  and  dissected 
back  to  their  origin  from  the  carotids.  The  posterior  cerebral 
arteries  will  be  found  running  backwards  round  the  crura  cerebri 
under  cover  of  a  bridge  of  arachnoid.  Together  with  the  three 
cerebellar  branches,  they  may  be  followed  to  a  short  distance 
and  then  divided.  It  will  now  be  found  that  the  circle  of 
Willis  is  retained  merely  by  the  numerous  minute  nutritive 
branches,  between  the  basilar  and  pons,  and  those  from  the 
anterior,  middle,  and  posterior  cerebrals,  which  pass  through 
the  anterior  and  posterior  perforated  spaces.  Gently  draw  these 
vessels  out  by  means  of  forceps  as  far  as  possible,  sever  them 
close  to  the  surface  of  the  brain,  and  then  float  off  the  vessels 
of  the  base  into  a  shallow  dish  or  plate  of  water,  arranging  the 
branches  in  their  relative  positions. 

Capacity  of  the  Arteries. — It  may  be  found  advisable  in 
certain  cases  to  test  the  relative  capacity  of  the  larger  vessels 
at  the  base,  and  this  may  be  obtained  approximately  by  means 
of  a  small  graduated  conical  gauge. 


332      METHODS  OF   PREPARING,  DEMONSTRATING,  ETC., 


In  making  these  comparisons  the  student  should  bear  in 
mind  that  the  united  areas  of  the  branches  equal  very  nearly  the 
area  of  the  trunk  from  which  they  originated,  although  their 
united  diameters  far  exceed  that  of  the  latter.  It  has  been  shown 
by  Paget's  measurements  that  the  equality  between  the  area  of 
the  trunk  and  of  its  branches  is  not  exactly  maintained,  the  area 
sometimes  increasing  in  the  vessels  of  the  upper  extremities 
and  head  and  neck,  and  diminishing  in  the  lower  extremities. 
Now,  according  to  the  mathematical  law  that  the  areas  of 
circles  are  as  the  squares  of  their  diameters,  it  will  be  seen  to 
be  necessary  to  contrast  in  our  measurements  the  square  of  the 
diameter  of  the  trunk  with  the  sum  of  the  squares  of  that  of 
the  branches  arising  from  it.  The  student  therefore  should 
proceed  in  the  following  manner :  Let  us  suppose  he  wishes  to 
estimate  the  relative  capacity  of  the  vessels  at  the  base  and 
their  primary  branches;  let  him  remove  these  vessels  as 
already  recommended,  and  float  them  out  in  a  shallow  vessel 
containing  water.  With  a  pair  of  sharp  scissors  cut  across  the 
vessel  exactly  at  right  angles  to  its  direction,  pass  the  gra- 
duated cone  into  it,  and  gently  draw  the  vessel  on  until  it  is 
fully  distended,  but  not  stretched,  by  the  gauge ;  read  off  the 
diameter  as  shown  on  the  gauge,  and  proceed  in  like  manner 
with  the  other  vessels.  Arrange  the  diameter  and  the  squares 
in  appropriate  columns,  opposite  the  names  of  the  vessels,  for 
future  comparison.  The  following  tables  represent  the  average 
measurements  of  the  various  vessels  at  the  base  in  forty-five 
cases  of  insanity  I  have  investigated : 


Diameter. 

Square. 

Vertebral  Artery — Right . 
Left    . 

mm. 
3-147 
3-42 
3-82 
2-658 
2-56 
3-951 
4-02 
3-133 
3-55 
2-73 
2-66 

mm. 

10-341 

12-039 

14-805 

7-213 

6-551 

15-789 

16  026 

10-063 

10-351 

7-55 

7-445 

Posterior  Cerebral — Right 
Left  . 

Left  .... 

Mid- Cerebral — Right  .     . 

Left     .     .     . 
Anterior  Cerebral — Right 
Left    . 

Thus  the  sums  of  the  square  of  the  diameters  of  the  anterior 


CEREBRAL   STRUCTURE   IN  HEALTH  AND  DISEASE.       333 

and  middle  cerebral  of  the  right  side  was  to  that  of  the  left 
side  as  17*613  to  17-796. 

The  square  of  the  diameter  of  right  and  left  anterior  and 
middle  cerebrals  amounted  in  the  aggregate  to  35*409,  both 
posterior  cerebrals  reaching  only  13*764. 

Contrasting  again  the  mid-cerebral  supply  of  both  sides 
with  that  of  both  anterior  cerebrals,  we  find  it  represented  by 
20*414  against  14*995. 

Reference  to  the  table  of  measurements  will  show  that  the 
posterior  and  anterior  cerebral  supply  of  both  sides  is  almost 
exactly  similar :  thus,  on  the  right  side,  we  find  7*213  con- 
trasted with  7*55  ;  and  on  the  left  side,  6*551  with  7*445. 

Another  interesting  feature  in  connection  with  these 
measurements  is  the  great  preponderance  in  areas  of  the  two 
vertebrals  over  the  basilar,  which  they  form  by  their  union. 
The  two  former  have  as  the  sum  of  the  square  of  their  dia- 
meters 22*38,  the  basilar  only  averaging  14*805 ;  and  in  several 
cases  I  have  found  the  basilar,  not  more  than  one-half  the  area 
of  the  united  vertebrals. 

It  may  assist  the  student  to  obtain  a  clearer  idea  of  these 
areas  if  he  represents  them  graphically  as  straight  lines  upon 
an  enlarged  scale. 

Vessels  of  the  Pia  Mater. — First  note  the  general  appearance 
and  distribution  of  the  vessels  of  the  pia  mater  as  they  lie 
in  situ.  Observe  the  relative  position  taken  by  the  veins  and 
arteries,  the  former  being  large  and  superficial,  the  latter  much 
smaller  and  concealed  chiefly  within  the  folds  of  pia  mater, 
which  dip  into  the  sulci  and  are  bridged  across  by  arachnoid. 
The  upper  aspect  in  health  being  arachnoid,  should  present  a 
smooth  endothelial  surface.  Use  a  hand-lens  in  examining  these 
vessels.  The  student  should  observe  any  fibrinous  effusions, 
purulent  exudates,  or  minute  extravasations  along  the  course  of 
the  blood-vessels,  the  presence  of  atheroma,  morbid  growths—  as 
gummata,  tubercle,  &c.  If  tuberculosis  be  suspected,  examine 
the  arteries  deep  in  the  sulci,  and  this  with  care,  as  tubercle 
along  the  course  of  the  vessels  is  found  with  far  greater  diffi- 
culty here  than  at  the  base  or  up  the  Sylvian  fissure. 

Next  strip  off  a  large  portion  of  arachnoid  and  pia  mater 
from  the  surface  carefully,  and  transfer  it  to  a  deep  vessel  con- 


334        METHODS   OF   PREPARING,   DEMONSTRATING,   ETC., 

taining  water,  the  arachnoid  surface  being  uppermost.  Observe 
the  velvety  aspect  of  the  lower  surface,  due  to  a  fine  pile  of 
blood-vessels,  and  the  very  rich  fringe  of  vessels  along  the 
intergyral  folds,  for  the  supply  of  the  cortex  deep  within  the 
sulci. 

Seize  with  forceps  one  of  these  richly  fringed  folds  and  snip 
off  a  portion  with  a  pair  of  scissors,  floating  it  on  to  a  glass 
slide,  with  its  vessels  disentangled  and  spread  out.  Eemove 
also  to  another  glass  slide  a  portion  of  the  membranes  detached 
from  the  summit  of  a  convolution,  and  study  it  by  means  of  a 
hand-lens,  both  in  reflected  and  transmitted  light.  Educate 
the  eye  in  this  manner  into  recognising  the  various  healthy 
and  morbid  structures  to  be  found  here. 

For  microscopic  purposes,  both  these  slides  last  mentioned 
should  be  reserved,  whilst  a  small  portion  of  brain  covered  by 
its  membrane,  and  including  two  adjacent  convolutions,  should 
also  be  set  aside.  These  will  afford  subjects  for  a  bird's-eye 
view  of  the  surface  under  low  powers  of  the  microscope,  such  an 
examination  being  always  insisted  upon  as  especially  valuable. 
The  portion  of  brain  must  then  be  frozen  and  cut  in  such  a 
direction  that  the  sections  so  obtained  represent  both  gyri 
with  the  intervening  sulcus  bridged  over  by  arachnoid.  We 
thus  obtain  very  beautiful  slides  for  fresh  examination,  which 
afford  us  the  opportunity  of  minute  examination  of  the  cortex 
and  the  connections  and  relationships  between  it  and  its 
membranes. 

The  large  superficial  veins  at  the  vertex  where  they  open 
into  the  longitudinal  sinus,  are  occasionally  found  plugged  by 
thrombi ;  they  should  therefore  always  be  examined  with  the 
object  of  ascertaining  the  nature  of  their  contents,  especially 
if  there  is  evidence  of  inflammation  of  the  dura  mater  and  its 
sinuses,  or  of  purulent  meningitis. 

The  student  should  also  take  every  opportunity  of  following 
up  the  arterial  branches  given  off  from  the  anterior,  middle,  and 
posterior  cerebral  arteries,  in  their  course  along  the  sulci,  until 
he  has  familiarised  himself  with  the  exact  supply  of  various 
regions  and  convolutions  of  the  brain.  It  is  only  necessary  to 
allude  to  the  work  of  Duret  and  Charcot  in  this  direction  to 
indicate  the  importance  of  a  minute  knowledge  of  the  arterial 


CEREBRAL   STRUCTURE   IN  HEALTH  AND  DISEASE.      335 

districts  of  the  encephalon  in  order  to  fully  appreciate  nume- 
rous lesions  met  with  in  the  brain. 

Nutrient  Vessels  at  the  base. — We  should  devote  attention  to 
the  numerous  vascular  tufts  which  arise  from  the  large  vessels 
at  the  base  for  the  supply  of  the  central  ganglia  and  pons 
Varolii.  Those  which  supply  the  basal  ganglia  are  disposed 
into  anterior  and  posterior  groups — the  former  arising  from  the 
anterior  cerebral,  anterior  communicating  and  middle  cerebral 
arteries;  the  latter  taking  origin  from  the  bifurcation  of  the 
basilar,  often  from  an  enlarged  posterior  communicating,  a 
further  series  arising  from  each  posterior  cerebral  artery  as 
it  winds  around  the  crura  cerebri.  Eoughly,  it  may  be  stated 
that  the  anterior  group  supplies  the  corpus  striatum  and  ante- 
rior extremity  of  the  thalamus  opticus,  whilst  the  posterior 
group  is  distributed  chiefly  to  the  thalamus. 

Note,  first,  their  remarkably  fine  calibre  considering  their 
direct  origin  from  main  arterial  trunks ;  and  secondly,  observe 
that  they  are  given  off  from  these  trunks  at  a  right  angle — a  sig- 
nificant fact,  as  they  can  only  be  affected  to  a  minimum  degree 
by  the  propulsive  wave  of  blood  caused  by  each  cardiac  systole. 
They  are  filled  therefore  by  a  sustained  lateral  pressure. 

An  examination  of  the  nutrient  supply  to  the  pons  will 
impress  the  student  with  the  following  facts : 

1st.  The  nutrient  twigs  arising  from  the  main  artery  are 
remarkably  small,  as  in  the  other  cases. 

2nd.  They  also  arise  at  right  angles  from  the  basilar 
artery. 

3rd.  The  basilar  is  but  slightly  over  half  the  capacity  of 
both  vertebral  arteries  which  supply  it. 

The  latter  fact,  which  I  have  already  demonstrated  by  mea- 
surement in  our  remarks  upon  arterial  capacity,  when  taken  in 
conjunction  with  the  other  two  data  warrants  us  in  assuming 
that  these  nutrient  branches  are  kept  constantly  filled  by  high 
lateral  pressure  and  exhibit  none  of  the  phenomena  of  the 
pulse.  I  need  not  insist  upon  the  beauty  of  this  arrangement  of 
means  to  an  end.  In  removing  the  vessels  at  the  base,  be  care- 
ful not  to  tear  these  nutrient  vessels  short,  but  with  gentle 
traction  draw  them  out  and  cut  them  across  with  fine  curved 


336      PREPARING,  ETC.,  CEREBRAL  STRUCTURE. 

scissors ;  float  the  circle  of  Willis  and  its  branches  in  a  shallow 
dish  of  water,  and  examine  the  various  nutrient  groups.  Snip 
off  some  of  the  anterior  and  posterior  tufts,  float  them  on  to  a 
slide,  arranging  the  branches,  and  examine  by  the  naked  eye  as 
well  as  by  microscopic  aid.  Wherever  arterial  degeneration  is 
suspected,  never  miss  the  opportunity  of  thus  closely  inspect- 
ing the  nutrient  supply  of  the  corpora  striata,  optic  thalami, 
and  pons  Varolii.  The  naked  eye  will  suffice  to  reveal  to  us 
aneurismal  dilatations  along  these  branches,  atheromatous 
degeneration,  thrombi  or  embolic  plugging,  often  explanatory 
of  haemorrhages  within  the  structure  of  the  basal  ganglia  or 
pons. 


(To  he  continued.) 


NERVOUS  DISEASES  IN  VICTORIA. 

BY   JAMES   JAMIESON,   M.D.,   MELBOURNE. 

The  question  of  the  influence  of  climate  in  the  causation  of 
disease  is  a  very  difficult  one ;  for  this  among  other  reasons, 
that  it  is  hardly  possible  to  eliminate  with  certainty  social 
and  other  associated  conditions.  I  am  not  prepared  to  say 
therefore  that,  in  this  contribution  to  the  very  obscure  subject 
of  the  etiology  of  nervous  diseases,  much  if  anything  has  been 
done  to  make  that  influence  plain.  In  itself,  however,  the 
subject  is  so  important,  and  the  data  accumulated  are  so 
scanty,  that  the  following  statistics  may  be  found  to  possess  a 
certain  value.  The  prevalence  and  fatality  of  nervous  diseases 
in  England  have  been  discussed  with  great  fulness  by  Dr. 
Althaus,  in  a  series  of  papers  in  the  '  Medical  Times  and 
Gazette '  for  1876,  afterwards  reprinted  with  additions.  I  pro- 
pose to  give  a  somewhat  similar,  if  less  elaborate,  discussion 
of  the  same  points  as  regards  the  colony  of  Victoria.  Before 
any  comparison  of  the  two  countries  is  made  with  reference  to 
the  mortality  from  these  diseases,  certain  things  must  be 
borne  in  mind  by  way  of  caution.  Even  now  the  population 
of  Victoria  has  not  the  same  composition  as  that  of  England 
as  respects  the  proportion  of  the  sexes  and  of  persons  living 
at  different  ages,  and  the  difference  becomes  more  marked  as 
we  go  back  to  the  time,  nearly  thirty  years  ago,  when  the 
discovery  of  gold  brought  so  many  immigrants  to  its  shores. 
So  great  has  been  the  change  that  it  is  not  even  easy  to  com- 
pare properly  our  own  condition  now  with  what  it  was  twenty 
years  ago,  as  tables  subjoined  will  show.  Social  conditions 
too  have  altered  greatly,  and  this  could  scarcely  be  proved  in 
a  clearer  or  more  striking  way  than  by  the  following  fact.  In 
VOL.   III.  z 


338 


NERVOUS   DISEASES  IN   VICTORIA. 


1854  there  were  no  fewer  than  70  deaths  from  delirium 
tremens,  with  a  population  of  312,000,  while  in  1878  there 
were  only  16  among  879,000  persons,  that  number  being  also 
the  average  for  five  years  preceding.  The  excitement  and 
recklessness  of  the  period,  when  the  gold  fever  was  at  its 
height,  subsided  gradually,  and  must  have  had  many  other 
effects,  though  these  may  not  be  so  easily  established  as  those 
following  the  excessive  use  of  alcohol.  To  these  points,  and 
to  others  which  may  suggest  themselves,  such  as  the  mixed 
character  of  our  population,  gathered  from  all  the  ends  of  the 
earth,  due  weight  must  be  given  if  any  comparison  is  to  be 
made  of  the  results  here  given  with  those  of  Dr.  Althaus. 

I  propose  to  compare  the  mortality  in  the  two  decennial 
periods,  1859-68  and  1869-78,  thus  bringing  down  our  know- 
ledge to  the  latest  point,  and  going  back  as  far  as  seems 
advisable  in  the  peculiar  circumstances.  As  preliminary  to 
the  others,  the  following  tables  supply  some  needful  informa- 
tion about  the  population,  taking  the  census  years  1861  and 
1871  as  the  basis.  It  would  have  been  better  if  these  could 
have  been  made  the  middle  years  of  periods  compared,  but  I 
have  thought  it  advisable  to  give  exact  figures  rather  than 
mere  estimates,  which  alone  can  be  given  for  other  years,  and 
they  at  least  afford  an  idea  of  the  difference  of  the  two  periods. 

TABLE   I. 

Showing  the  Numbers  of  Persons  living  at  different  Ages  in  Victoria 
in  1861  and  1871. 


Under  5  years    . 
5  to  10     „ 
10  to  20     „ 
20  to  45     „ 
Above  45  „ 

1861. 

1871. 

91,514 
53,265 

67,652 

272,844 

45,047 

116,688 
106,503 
140,131 

275,900 
92,296 

Total  at  all  ages    . 

540,322         731, 5.18 

NERVOUS   DISEASES  IN   VICTORIA. 


339 


TABLE    II. 

Showing  the  Percentage  of  Persons  living  at  different  Ages  in  Victoria 
in  1861  and  1871,  and  in  england  in  1871. 


VICTORIA. 

ENGLAND. 

1861. 

1871. 

1871. 

Under  5  years 

16-93  p.  cent. 

15*95  p.  cent. 

13-52  p.  cent. 

5  to  10      „        ... 

9-85        „ 

14-56 

11-91        „ 

10  to  20      „        ... 

12-52 

19-15 

20-27 

20  to  45      „        ... 

50-49        „          37-71 

34-85 

Above  45    „        ... 

8-33        „           12-61        „ 

1 

19-43 

Considering  the  smallness  of  the  figures  to  be  handled,  I  have 
not  thought  it  necessary  to  subdivide  more,  and  the  distinction 
of  infants,  children,  youths,  adults,  and  old  people,  is  sufficient. 
A  gradual  approximation  to  the  English  proportions  is  shown, 
but  it  is  probable  that  even  in  1878  differences  were  still  very 
considerable.  In  the  next  table  I  have  subdivided  even  less, 
both  for  the  above  reason  and  because  up  to  twenty  years  of 
age  males  and  females  are  about  equal  in  numbers. 


TABLE   III. 

Showing  the  Numbers  of  Males  and  Females,  at  different  Ages  in 
Victoria  in  1861  and  1871. 


Under  20  years    . 
20  to  45      „ 
Above  45    „ 

1861. 

mi. 

Males. 

Females. 

Males. 

Females. 

106,874 
190,603 
31,174 

105,640 
92,185 
13,846 

186,507 
169,159 

65,384 

185,932 

114,435 

30,111 

Totals  at  all  ages 

328,651 

211,671 

401,050 

330,478 

P.  cent,  of  each  sex 

68-25% 

31-75% 

54-82  % 

45-18% 

z  2 


340 


NERVOUS   DISEASES  IN   VICTORIA. 


Even  now  males  considerably  exceed  in  number  the  females 
in  Victoria,  though,  as  is  shown  above,  there  has  been  a  some- 
what rapid  approach  to  equality  in  the  ten  years. 

•  TABLE    IV. 

Showing  the  Deaths  from  all  causes,  and  the  Comparative  Mortality 
from  Zymotic,  Tubercular,  Nervous,  and  Respiratory  Diseases'  in 
Victoria  in  two  Decennial  Periods. 


Zymotic  diseases  . 

1859-68. 

1869-78. 

34,739  =  33-06  % 

34,438  =  29-56  % 

Tubercular  diseases  . 

•    10,820  =   10-29  „ 

12,558  =  10-47  „ 

Nervous  diseases . 

10,751   =   10-23  „ 

13,196  =   11-01  „ 

Respiratory  diseases 

8,976  t=     8-54  „ 

12,627  =   10-53  „ 

All  causes     .... 

105,068            — 

119,848            — 

Of  these  four  classes,  that,  of  zymotic  diseases  showed  the 
most  marked  fluctuations,  as  might  have  been  expected,  while 
that  of  nervous  diseases  did  not  show  very  great  variations 
from  year  to  year.  To  some  extent  there  was .  observable  a 
tendency  to  the  variations  in  the  two  classes  of  cases  to  follow 
a  parallel  course,  the  deaths  from  both  being  greatest  in  the 
three  years  J 860,  1866,  and  1867,  of  the  first  decennium ;  and 
in  1875  and  1876,  which  were  great  epidemic  years,  the  mor- 
tality from  nervous  diseases  was  also  ^nuch  above  the  average. 
This  may  have  been  accidental,  as  a  similar  concomitant  varia- 
tion does  not  seem  to  have  been  observed  in  England.  While 
the  mortality  from  zymotic  diseases  compared  with  the  total 
is  higher  in  Victoria,  that  from  nervous  diseases  is  distinctly 
lower  than  in  England,  averaging  10  '64%  in  the  twenty  years 
1859-78  as  against  12  26%. 

The  great  blot  on  these  statistics  is  the  largeness  of  the 
proportion  of  cases  vaguely  registered  as  "Disease,"  and  it 
introduces  a  further  difficulty,  in  addition  to  those  already 
given,  in  the  way  of  a  proper  detailed  comparison  of  the  mor- 
tality from  particular  forms  of  disease  in  Victoria  and  in 
England,  where  there  has  been  more  strictness  shown.     A  few 


NERVOUS   DISEASES  IN   VICTORIA. 


341 


TABLE   V. 

Showing  the  Deaths  from  the  several  Diseases  of  the  Nervous  System 
in  Victoria,  and  their  percentage  of  the  entire  Mortality  from 
the  same  causes. 


words  on  the  general  results  as  regards  each  cause  may  be 
allowable. 

I.  Cephalitis  appears  to  be  a  much  more  frequent  cause  of 
death  here  than  in  England,  where  the  average  for  a  long 
period  has  been  only  6 '  64  per  cent.,  with  a  slight  but  steady 
rise  of  late  years.  The  difference  between  that  figure  and  the 
Victorian  average  of  16  •  29  per  cent,  is  very  great,  and  is 
not  to  be  accounted  for  by  the  different  constitution  of  the 
population  as  respects  age. 

II.  Apoplexy  had  become  considerably  more  fatal  in  the 
second  period,  probably  owing  in  great  part  to  the  greater 
proportion  of  persons  above  middle  life,  but  it  is  curious  to 
note  that  the  percentage  had  become  higher  here  than  in 
England  (16*19%  average,  maximum  17*85%),  even  though 
the  number  of  old  people  was  much  smaller  in  Victoria,  as 
shown  in  Table  II. 

III.  Paralysis,  for  the  same  reason  doubtless  as  in  the  case 
of  apoplexy,  caused  a  larger  number  of  deaths  in  the  second 
decennial  period,  differing  from  it  in  this  important  respect 


342  NERVOUS  DISEASES   IN   VICTORIA. 

that  even  iu  the  second  the  percentage  of  mortality  was  still 
very  much  lower  than  in  England,  where  it  had  been  showing 
a  rapid  and  steady  increase  (average  15  96%,  maximum 
18*11%).  It  is  not  easy  to  say  with  certainty,  whether  the 
higher  rate  in  England  is  satisfactorily  accounted  for  by  the 
greater  number  of  old  people,  or  whether  the  tendency  of 
disease  to  assume  a  more  acute  course,  rather  than  to  lead  to 
chronic  degenerative  changes,  in  the  dry  stimulating  climate 
of  Australia,  helps  to  bring  about  an  apparently  slighter 
liability  to  paralysis  and  other  forms  of  disease  usually 
dependent  on  structural  degenerations. 

IY.  Insanity  has  been  a  less  frequent  cause  of  death  in  the 
last  decennium,  having  fallen  from  0  ■  82%  to  0  •  49%,  or  only 
about  half  of  the  English  average.  The  figures  for  Victoria 
are  so  small,  however,  that,  independently  of  other  sources  of 
difficulty,  it  is  not  easy  to  be  sure  that  our  average  is  a  fair 
one.  It  at  least  does  not  show  any  tendency  to  an  increase  of 
mortality  from  that  cause  here. 

V.  Chorea  here  as  elsewhere  rarely  proves  fatal,  and  the 
mortality  of  the  last  ten  years  has  been  just  about  the  same 
proportion  as  in  England. 

VI.  Epilepsy  has  shown  a  very  decided  increase,  and  in  the 
last  ten  years  had  become  slightly  more  fatal  than  in  England, 
where  it  has  also  produced  a  steadily  higher  death-rate.  The 
difference  between  the  two  countries,  however,  is  too  slight  to 
call  for  observation. 

VII.  Convulsions,  here  as  in  England,  form  the  most  frequent 
cause  of  death  among  the  nervous  diseases.  The  mortality 
produced  by  them  is  almost  wholly  among  young  children, 
and  considering  that  these  form  a  considerably  higher  pro- 
portion of  the  population  here  it  might  have  been  expected 
that  the  death-rate  would  also  have  been  higher.  Quite  the 
opposite,  however,  has  been  the  case,  for  while  the  average  for 
a  long  period  in  England  has  been  48*70%  of  the  total 
mortality,  in  Victoria  it  was  36  ■  09%  in  the  ten  years  1859-68, 
and  fell  to  26*63%  in  1869-78,  or  an  average  for  the  whole 
twenty  years  of  30*88%.  I  do  not  think  that  cases  of  death 
from  convulsions  could  frequently  have  been  registered  under 
another  term,  not  even  under  "  Brain  disease,"  the  symptoms 


NERVOUS   DISEASES   IN   VICTORIA.  343 

being  so  unmistakable.1  The  only  suggestion  I  can  make  in 
the  way  of  explanation  is  the  almost  complete  freedom  from 
rickets  of  the  children  in  this  country,  that  disease,  according 
to  Dr.  Gee,  supplying  the  predisposition  without  which  con- 
vulsions are  either  comparatively  infrequent  or  at  least  seldom 
fatal.  Though  that  doctrine  has  been  accepted  by  Dr.  Hugh- 
lings  Jackson  and  others,  it  has  been  sometimes  pushed  too 
far,  as  by  Dr.  Hillier.  My  own  experience  is  that  convulsions 
are  far  from  uncommon  in  this  country,  but  that  the  exciting 
cause  is  almost  invariably  peripheral  irritation,  and  in  a  large 
proportion  of  cases  merely  gastro-intestinal  irritation  resulting 
from  the  ingestion  of  unsuitable  food.  It  may  be  that  the 
relatively  low  mortality  is  owing  to  the  absence  of  the  rickety 
state  of  the  constitution,  so  that  recovery  is  easy,  the  exciting 
cause  being  removable,  and  essentially  temporary  in  its 
action. 

VIII.  Brain  disease,  dec. — Whilst  the  large  number  of 
deaths  registered  in  this  vague  way  makes  a  comparison  of  the 
Victorian  conditions  with  those  in  England  less  easy  and 
exact,  the  proportions  in  the  two  decennial  periods  are  so 
nearly  alike  that  a  comparison  of  these  is  not  interfered  with. 
The  diminution  in  the  second  period  is  no  doubt  owing  to 
more  care  in  diagnosis,  and  perhaps  to  greater  exactness  being 
insisted  on  by  the  Registrar-General. 

For  the  sake  of  completeness,  something  may  be  said  about 
the  influence  of  sex  on  the  mortality  from  diseases  of  the 
nervous  system. 

It  is  unnecessary  to  make  any  extended  remarks  on  this  table 
(Table  VI.) ;  but  it  is  curious  to  note  to  what  a  slight  extent  the 
mortality  among  females  had  increased  in  the  second  period 
compared  with  the  relative  increase  in  the  female  population. 

1  Though  there  could  scarcely  be  auy  mistake  about  the  existence  of  convulsions, 
there  is  some  liability  to  error  in  the  form  of  the  registration  certificate ;  and  it  is 
possible  that  some  deaths,  actually  produced  by  convulsions,  may  have  been  put 
down  as  having  their  cause  in  "  Dentition,"  that  refuge  of  the  man  who  is  careless 
in  his  diagnosis.  It  may  be  said  that  there  is  the  same  possible  fallacy  in  the 
English  figures,  and  that  a  comparison  therefore  still  holds  good.  Very  many 
deaths  have  been  registered  as  from  "Dentition,"  in  Victoria,  no  fewer  than 
3716  in  the  ten  years,  1859-68.  In  the  second  period,  1869-78,  the  number  was 
only  1881,  so  that  even  if  strict  account  could  be  taken,  the  diminution  in  the 
death-rate  from  convulsions  of  late  years  in  Victoria  must  be  regarded  as  certain. 


344 


NERVOUS   DISEASES  IN   VICTORIA. 


TABLE  VI. 

Showing  the  Number  of  Deaths  and  percentage  op  Mortality  from  the 
several  Diseases  of  the  Nervous  System  in  Males  and  Females. 

First  Period,  1859-68. 


Cephalitis 

Males. 

Females. 

991    =     9-21    % 

703  =     6-53  % 

Apoplexy 

1059  =     9-85  „ 

444  =     4-13  „ 

Paralysis 

439  =     4-08  „ 

225  =     2-09   „ 

Insanity 

62  =     0-57  „ 

27  =     0-25   „ 

Chorea 

3  =     0-02  „ 

15  =     0-14   „ 

Epilepsy 

177  =     1-64  „ 

147  =     1-36   „ 

Convulsions    . 

2072  =  19-27  „ 

1809  =   16-82   „ 

Brain  diseases,  &c.    . 

1629  =   15-15   „ 

949  =     8-82  „ 

Total  nervous  diseases  . 

6432  =  59-83  % 

4319  =  40-17  % 

Second  Period,  1869-78. 


Cephalitis       .... 

Convulsions    K     .     .     . 
Brain  diseases,  &c.    . 

Males. 

Females. 

1242  =     9-41  % 

1591   =  12-05  „ 

887  =     6-72  „ 

35  =     0-26  „ 

4  =     0  03  „ 

300  =     2-27  „ 

1898  =  14-38   „ 

1815  =  13-75   „ 

980   =     7-42  % 

1002  a     7-59   „ 

515  =     3-90  „ 

30  =     0-23  „ 

11   =     008  „ 

262  =     1-98  „ 

1616  =   12-25   „ 

1008  =     7-64   „ 

Total  nervous  diseases. 

7772  =  58-90  %             5424  =  41-10  % 

The  greater  number  of  males  above  forty-five  years  counter- 
balanced  the   effect   produced   by  the  higher   proportion   of 


NERVOUS   DISEASES   IN   VICTORIA. 


345 


females  between  twenty  and  forty-five  years.  The  observation 
of  Dr.  Althaus,  that  males  are  more  liable  to  die  of  diseases  of 
the  nervous  system  than  females,  is  confirmed  by  the  Victorian 
figures ;  for  while  58  ■  41  per  cent,  of  the  deaths  from  all  causes 
occurred  among  females  in  1859-68,  the  male  mortality  from 
diseases  of  the  nervous  system  was  59*83  per  cent.;  and  in 
1 869-78  the  proportions  were  57  ■  44  and  58  ■  90  per  cent. 

No  account  has  been  taken  in  the  above  tables  of  the  deaths 
from  tetanus  and  from  delirium  tremens.  Tetanus  finds  no 
mention  in  our  returns  of  Vital  Statistics,  and  delirium 
tremens  is  classed  with  the  zymotic  diseases,  though  it  might 
perhaps  with  some  propriety  have  been  ranked  among  those  of 
the  nervous  system.  Judging  by  the  mortality  it  must  once 
have  been  excessively  prevalent  in  Victoria,  as  shown  by 
figures  given  at  the  beginning  of  this  article.  The  death-rate 
from  it  has,  however,  undergone  a  steady  diminution,  though  it 
is  still  considerably  higher  than  that  of  England. 

TABLE   VII. 

Showing  the  Numbeb  of  Deaths  fbom  Delirium  Tremens,  and  its  per- 
centage of  Mortality  among  all  Diseases  of  the  Nervous  System  in 
Males  and  Females,  and  for  both  sexes. 


1859-68     .      .      . 
1869-78     .      .      . 

Males. 

269  =  2-43  % 
153  =  JL-14  „ 

Females. 

Both  Sexes. 

45   =  0-40  % 
40  =  0-30   „ 

314  =  2-83  % 
193  a   1-44   „ 

These  figures  show  a  distinct  and  satisfactory  improvement, 
though  the  lower  averages  are  still  above  the  English,  which 
for  1867-71  were,  males  0*55%,  females  0*10%.  In  conclusion, 
I  append  a  list  of  the  various  diseases  arranged  in  the 
order  of  their  fatality,  and  I  have  thought  it  best  to  take 
the  results  of  the  second  period,  when  our  population  had  got 
into  something  like  a  settled  condition.  If  the  total  of  the 
percentages  is  found  to  amount  to  more  than  one  hundred,  the 
explanation  is  to  be  got  in  the  fact  that  the  delirium  tremens 
figures  have  been  added  after  the  others  were  calculated. 


346  NERVOUS   DISEASES  IN   VICTORIA. 

Convulsions 26  •  63  per  cent. 

Brain  diseases,  &c 21*39  „  „ 

Apoplexy 19*65  „  „ 

Cephalitis 16*83  „  „ 

Paralysis 10*62  „  „ 

Epilepsy 4*25  „  „ 

Delirium  tremens        .      .      .      .  1  *  44  „  „ 

Insanity 0*49  „  „ 

Chorea 0*11  „  „ 

This  arrangement  differs  greatly  from  that  given  by  Dr. 
Althaus  for  England,  and  I  am  sorry  that  it  has  not  been 
possible  to  give  a  more  definite  account  of  the  causes  of  the 
differences.  I  have  endeavoured  to  apply  tolerably  complete 
data,  and  a  little  consideration  will  enable  any  one  interested 
to  see  how  great  are  the  difficulties  in  the  way  of  any  such 
explanation. 


A  PLEA  FOR  THE  MINUTE  STUDY  OF  MANIA.1 

BY   J.    CRICHTON-BROWNE,   Ut.D.   EDIN.,   LL.D.,   F.R.S.E. 

Lord  Clmncellor s  Visitor  of  Lunatics. 

Any  one  accustomed  to  the  literature  of  general  medicine,  and 
turning  to  that  of  psychological  medicine  for  the  first  time, 
must,  I  think,  be  struck  by  the  comparative  paucity  of  reports 
of  cases  in  the  latter,  or  at  least  of  reports  of  cases  intended  to 
illustrate  diagnosis,  or  the  grouping  of  symptoms  in  mental 
diseases.  True,  in  our  special  journals,  and  also  in  non-special 
journals,  cases  of  insanity  may,  from  time  to  time,  be  found 
described  ;  but  these  are  almost  invariably  published,  because 
they  illustrate  the  success  or  futility  of  some  kind  of  treatment, 
or  the  morbid  anatomy  of  some  coarse  lesion  in  the  nerve- 
centres,  and  not  because  they  are  typical  of  any  variety  of 
psychical  derangement.  The  records  of  cases  indeed  which 
are  issued  from  lunatic  asylums,  whatever  be  the  motive 
of  their  publication,  are  singularly  deficient  in  information 
bearing  on  the  modifications  of  the  higher  cerebral  functions, 
and  many  of  us  would  be  puzzled  at  this  moment,  were  we 
asked  by  any  zealous  student,  to  refer  him  to  a  series  of  clini- 
cal delineations  which  would  convey  to  him  a  just  conception 
of  the  nature  and  procession  of  the  impairments  of  the  senses 
and  intellect,  or  perversions  of  the  emotions  and  will,  which 
correspond  with  the  commonest  forms  of  insanity.  Perhaps 
the  best  and  most  vivid  sketches  we  possess  are  those  con- 
tained in  a  few  of  our  text-books,  and  in  the  writings  of  some 
of  the  older  authors  on  our  subject,  but  even  these  have  not 
always  been  taken  from  nature.  Some  of  them  commend 
themselves  to  us  by  their  literary  rather  than  their  scientific 

1  Read  in  the  Psychological  Section  of  the  British  Medical  Association  Meeting 
at  Cambridge,  August,  1880.  . 


348     A   PLEA   FOR   THE   MINUTE    STUDY   OF   MANIA. 

merits,  sacrificing,  as  they  occasionally  do,  the  angularity  of 
a  fact  to  the  rounding  of  a  period,  and  darkening  knowledge 
by  mere  rhetorical  flashes. 

If  we  inquire  the  reason  of  this  paucity  of  clinical  reports 
of  cases  of  insanity,  we  shall,  I  believe,  find  that  it  is  to  be 
attributed  to  several  causes.  In  the  first  place,  asylum  medical 
officers  have  been  called  on  hitherto  to  give  so  large  a  pro- 
portion of  their  time  and  energy  to  administrative,  sanitary 
and  routine  duties,  that  they  have  had  little  left  to  expend  on 
minute  and  tedious  observations  at  the  bedside  or  in  the  wards. 
Without  clinical  clerks,  or  with  a  very  inadequate  number,  they 
have  had  to  keep  their  own  medical  records,  and  have  therefore 
confined  these  within  narrow  limits,  and  made  them  of  an 
eminently  practical  character.  Thus  it  has  come  about  that 
the  case-books  of  most  asylums  have  been  kept  for  official 
rather  than  scientific  purposes,  and  do  not  afford  the  informa- 
tion that  is  necessary  for  the  preparation  of  clinical  reports. 
In  the  second  place,  the  medical  men  who  enter  asylum  practice 
are  ordinarily  unprepared  by  previous  training  to  sift  and  classify 
the  special  phenomena  that  then  fall  under  their  notice,  even 
if  they  had  the  leisure  and  disposition  to  do  so.  Unacquainted 
with  the  physiology  of  mind,  they  are  bewildered  by  its  mor- 
bid manifestations,  and  lack  that  knowledge  of  terms  and 
those  habits  of  thought  that  are  essential  to  an  accurate 
analysis  of  psychical  derangements.  In  the  third  place,  the 
observation  of  aberrations  of  mind  is  exceedingly  difficult  and 
laborious,  even  to  those  who  are  qualified  for  the  task,  and 
hence  few  have  had  the  intrepidity  to  undertake  it.  And  in 
the  fourth  place,  the  attempts  as  yet  made  in  this  direction 
have  not  proved  of  much  real  value,  while  their  speculative 
interest  has  not  served  to  secure  perseverance  in  them.  No 
practical  benefit  or  guidance  has  seemed  to  accrue  from  any- 
thing beyond  a  vague  and  general  survey  of  the  mental  con- 
dition in  insanity,  and  so  we  have  learnt  to  be  content  with 
comprehensive  phrases,  such  as  excitement,  depression  and 
incoherence,  and  have  had  little  encouragement  to  draw  up 
inventories  of  symptoms,  which  we  invariably  failed  to  connect 
with  pathological  changes. 

And  yet.  notwithstanding  this  deficiency  of  clinical  records 


A   PLEA   FOR    THE   MINUTE   STUDY  OF   MANIA.     349 

of  insanity  and  disregard  of  its  psychical  aspects,  most  of  those 
engaged  in  lunacy  practice  have   had  to  give   considerable 
attention,  in  certain  cases,  to  those  mental  symptoms  in  which 
alone,  for   legal  and   social  purposes,   insanity  consists.      In 
mania   they  may   have   attempted   no   analysis  of  the  over- 
whelming disorder  of  mind,  but  in  partial  insanity  they  have 
been  compelled  to  search  out  its  weak  points,  and  to  ascertain 
in  what  respects  it  has  departed  from  its  healthy  state.     To 
do  this  they  have  had  to  practise  what  I  shall  venture  to  call 
ideo-diagnosis.     They  have  had  to  stimulate  by  their  ideas 
the  mind  which  they  desired  to  examine.     Just  as  in  testing 
the   electric  reactions  of  muscles   and  nerves  we  apply  the 
electrodes  at  various  points  of  the  cutaneous  surface,  and  note 
the  results,  so  in  testing  the  state  of  the  mind  we  apply  our 
ideas,  as  it  were,  at  various  points  of  its  surface;  we  travel 
over  it  more  or  less  systematically,  gauging  its  ideo-sensibility 
and  irritability  as  we  go,  and  determining  as  best  we  may, 
whether  and  to  what  extent  they  are  increased,  perverted,  or 
abolished.     But  what  we  travel  over  in  this  way,  when  prac- 
tising ideo-diagnosis,  is  but  a  scheme  of  mind  which  we  have 
constructed  for  ourselves.     Doubtless  our  skill  as  specialists 
and  expertness  in  detecting  insanity,  when  it  is  latent  or  con- 
cealed, will  depend  in  great  measure  on  the  thoroughness  of 
that  scheme  and  the   ingenuity  with  which  we  pursue   the 
researches  to  which  it  guides  us ;  but  even  the  most  thorough 
scheme  hitherto  devised  is  artificial  after  all,  and  however  it 
may  help  to  establish  the  existence  of  insanity,  will  not  aid  us 
in  that  medical  diagnosis  which  we  should  strive  to  attain  to. 
For  our  scheme  of  mind  does  not  harmonise  with  any  scheme 
of  brain,  and  our  exploration  is  not  conducted  in  accordance 
with  our  knowledge  of  cerebral  topography  ;  and  hence  if  we 
come  upon  what  is  apparently  a  tolerably  isolated  patch  of 
diseased  mind,  we  are  utterly  incompetent  to   indicate   the 
whereabouts  of  its  pathological  substratum.     But  it  seems  to 
me  that  standing  as  we  do  in  the  light  of  modern  researches 
into  the  functions  of  the  brain,  we  cannot  be  content  any 
longer  with  this  old  style  of  ideo-diagnosis,  but  must  work  in 
all  cases  of  insanity  towards  a  localisation  of  the  lesion,  and  a 
recognition  of  its  nature.     We  must  aim  at  an  anatomical  and 


350      A   PLEA   FOR   THE   MINUTE   STUDY